Record of Investigation Into Death (Without Inquest)
Coroners Act 1995
Coroners Rules 2006
I, Stephen Raymond Carey, Coroner, having investigated the death of
Sadie Olive PARSELL
WITHOUT HOLDING AN INQUEST
(a) The identity of the deceased is Sadie Olive Parsell (Mrs Parsell) who died on 21 August 2010 at the Royal Hobart Hospital, (RHH), Hobart.
(b) Mrs Parsell was born on 31 December 1922, was aged 87 years and was widowed.
(c) Ms Parsell was retired and residing at the Barrington Lodge Nursing Home in New Town at the time of her death.
(d) Mrs Parsell died as a result of the combined effects of hypertensive cardiovascular disease and emphysema. A significant contributing factor was a recent fall from standing height with resultant fracture of the right neck of the femur.
Circumstances Surrounding the Death :
Mrs Parsell has a significant medical history. In 1991 she was in a motor vehicle accident which necessitated that she be hospitalised for a three month period in Intensive Care. Mrs Parsell suffered a stroke shortly after this. There were various hospitalisations following this for pneumonia episodes and in August 2009 Mrs Parsell suffered a virus which led to her hospitalisation and an overall decline in her health. In early 2010 Mrs Parsell suffered a stroke.
In the twelve month period prior to her death Mrs Parsell had a number of falls. These falls prompted her move from her home in Bellerive to the Barrington Lodge Nursing Home (the Home) in New Town. Mrs Parsell had resided at the Home for three months prior to her death.
Mrs Parsell’s daughter, Kathleen Downham visited Mrs Parsell every day and states that she has no concerns about the way the staff treated her mother nor any other concerns about the facility as a whole. On 19 August 2010 at approximately 6.30pm she received a call from the Home advising her that her mother had fallen. Ms Downham attended the Home within 5 minutes of the call to find Mrs Parsell in a chair with staff around her. Mrs Parsell was conscious and "did not appear overly distressed". Ms Downham states that it then became apparent that her mother had sustained a hip injury requiring hospital treatment and an ambulance was called.
Ambulance Tasmania has reported that "the fall was reported to have occurred at 15.30 and the call to Ambulance Communications was made at 1900. At the point of call, Ambulance Tasmania Southern Region was busy with a high case load of both emergency and non emergency and non emergent work. There was also a significant amount of ramping at the Royal Hobart Hospital. The caller was advised of this and he appeared fine with this advice…… The ambulance arrived at 2220." Ambulance Tasmania further reports that "there was further questioning around any obvious life threatening medical conditions, all of which were answered ‘no’."
Mrs Parsell was presented to the Department of Emergency Medicine at the Royal Hobart Hospital and was triaged at 23.29 hrs. She was diagnosed with a fractured neck of the femur and anaemia. She received 3 units of red blood cells. On 20 August at approximately 8.00pm she was moved to the Orthopaedic ward. Mrs Parsell following orthopaedic and medical review was assessed as medically unsuitable for surgery. Comfort measures were provided, her condition deteriorated and she died at approximately 11.00 am on 21 August 2010.
Dr Donald Ritchey, Forensic Pathologist carried out an autopsy of Mrs Parsell which was limited to an external examination and review of medical records. A toxicology examination was not performed. He reports:
"Her previous medical history is significant for severe chronic obstructive pulmonary disease with bronchiectasis and recurrent pneumonia, shortness of breath on ambulation, hypertension, chronic renal failure and anaemia……….
"……..the cause of death of this 87 year old woman, Sadie Olive Parsell, was the combined effects of hypertensive cardiovascular disease and emphysema. A significant contributing factor was a recent fall from standing height with resultant fracture of the right neck of femur."
"Ms Parsell was in her usual state of health at her nursing home when she suffered an unwitnessed fall from standing height during which she suffered a fracture to the neck of the right femur (right hip). She was transported by ambulance to the Royal Hobart Hospital where evaluation confirmed the hip fracture. She was admitted to the Orthopaedic Ward where, whilst being evaluated for possible surgical intervention became unresponsive and died. "
I am satisfied that a full and detailed investigation has been undertaken in relation to the death of Mrs Parsell and that there are no suspicious circumstances.
I find that Mrs Parsell died as a result of hypertensive cardiovascular disease and emphysema with contributing factors being a fall from standing a fracture of the right neck of the femur (hip fracture), hypertension, chronic renal failure and chronic anaemia.
Ms Downham has expressed concern in relation to the time taken for the ambulance to attend. I acknowledge that there was a delay of some 3 hours, 20 minutes between the time of the call and the attendance of the ambulance.
Apparently there were significant demands upon available ambulance resources on the evening of 19 August 2010. There was no assessment by those caring for Mrs Parsell of any obvious life threatening condition and unfortunately other work was given a higher priority. Although this was unfortunate and may have caused pain and discomfort to Mrs Parsell, I do not believe given the overall circumstances that this delay played any significant part in her death.
I wish to conclude by conveying my sincere condolences to the family of Mrs Parsell.
DATED: 3 May 2011 at Hobart in the State of Tasmania.