An 84-year-old man died from a head injury that could have been prevented if crucial safety information had been properly shared between hospital units, a coroner has found.
The retired engineer, who had Parkinson’s disease, was found shuffling on his bottom into a hallway at Calvary St John’s Rehabilitation Unit in South Hobart on June 19, 2024.
Coroner Olivia McTaggart said he had fallen backwards, struck his head on the floor and was unable to get up. He died nine days later from a brain injury.
McTaggart found the man had been assessed as needing a patient supervisor at Calvary Lenah Valley Hospital due to his high risk of falls and worsening cognitive state.
But that critical information was not passed on when he was transferred to the rehabilitation unit.
“If this measure had been in place, his fall would likely not have occurred,” McTaggart said in her newly published findings.
The man had scored 13 out of 30 on a mental state test, showing moderate dementia and had already fallen twice during his hospital stay.
Calvary’s Director of Clinical Services admitted the man’s transfer should have been delayed until his cognitive condition was properly investigated.
The failure to communicate the patient’s need for a sitter was an oversight at the time and should have been included in the handover information, the hospital indicated to the coroner.
Since then, Calvary has introduced electronic alerts for patients needing supervisors and tightened its pre-admission screening.
Patients requiring constant supervision are now excluded from rehabilitation programs.
The coroner recommended ongoing reviews of supervision assessments and handover processes to help prevent similar deaths.
