Death finding overturned

Coroner verdict on elderly woman’s RHH fall

A PREVIOUS coronial finding that the death of a “fiercely independent” elderly woman was preventable, following a fall at Royal Hobart Hospital, has now been overturned.

An inquest into the December 2015 death of Alice Mary Fowler was reopened late last year after a nurse who was caring for the 91-year-old said the findings had impacted negatively on her.

This week, Coroner Simon Cooper officially overturned the 2018 findings of Coroner Rod Chandler, who had found the hospital had failed to employ measures to keep Mrs Fowler safe, noting a “serious shortcoming in the standard of care required”.

Mrs Fowler died from a pelvic haematoma after falling from her hospital bed.

At a hearing in December last year, nurse Uma Kennedy said she was not given the chance to respond to Mr

Chandler’s findings and that she had only spent a limited amount of time caring for the West Hobart resident.

Mr Cooper said parts of the previous coronial finding – which said Mrs Fowler’s risk of falling had not been comprehensively assessed or prevention strategies put in place – could be read as a criticism of Ms Kennedy without having afforded her procedural fairness.

“In other words, she was not given an opportunity to put her side of the story,” he said in his findings.

Mr Cooper said the new inquest was held afresh, not as a review of the previous findings, and found Ms Kennedy only nursed Mrs Fowler for 75 minutes, not having sufficient time to complete a falls risk assessment.

The subsequent three nurses didn’t complete the paperwork either. “… I think it is important to make the point that whatever the deficiencies in relation to the completion of paperwork relating to Mrs Fowler, any such deficiencies did not cause her death,” he said.

Mr Cooper said her death was not preventable, with nursing staff lowering the bed, raising the side rails and providing a nurse call button.

“A number of measures were canvassed at the inquest including the use of sitters, high-low beds, and the like, but it is apparent to me that all or any of those measures could not have prevented Mrs Fowler from falling and fracturing her hip.”

However, Mr Cooper said there were deficiencies in Mrs Fowler’s care and that her age and history of falls should have been a “red flag” for staff.

He noted the failings should not be attributed to individual staff members and that the hospital had since upgraded its systems.