Record of Investigation into Death (Without Inquest)
Coroners Act 1995
Coroners Rules 2006
I, Christopher Webster, Coroner, having investigated the death of
WITHOUT HOLDING AN INQUEST
Find That :
Albert Shaw (Mr Shaw) died on 13 November 2008 at the Royal Hobart Hospital (RHH) in Tasmania.
Mr Shaw was born in Yorkshire in England on 2 February 1923 and was aged 85 years. He was a widower and a resident at the Strathaven Nursing Home (Strathaven) at Berridale a suburb north of Hobart.
I find that Mr Shaw died of a subdural haematoma following a fall at Strathaven. Contributing factors were Parkinsonism and dementia.
Circumstances Surrounding the Death :
Mr Shaw was born in Yorkshire in England. He married in 1950 and migrated to Tasmania with his family in 1967.
He had a past medical history of Alzheimer’s, ischaemic heart disease, Parkinson disease, depression, gatro-oesophageal reflux disease (GORD) and Osteoarthritis.
In April 2007 Mr Shaw and his wife became residents at Strathaven. When his wife died later in the year, Mr Shaw’s health appeared to deteriorate. He was transferred to the Ibis wing which is a secure unit for patients suffering from dementia. He was placed on a regular ‘sighting’ order which necessitated that a record be kept of his location every 15-30 minutes.
Mr Shaw was assessed as being at high risk of falling during his period of residence at Strathaven. He wore hip protectors and knee pads. A bed sensor was installed which alerted staff if he got out of bed over night.
Mr Shaw had 4 falls between June and October 2008 at Strathaven. The most noteworthy was an incident on 23 June 2008 where he fell in the shower and was transported to the RHH for treatment. He was diagnosed with a large haematoma and laceration to the scalp. A CT scan of his brain excluded a skull fracture and intracranial haemorrhage. An X-ray of one of his fingers revealed an open dislocation. His injuries were treated and he was discharged back to the nursing home with an oral antibiotic.
On 26 June 2008 Mr Shaw was referred back to the RHH after an ultra sound revealed the presence of a pseudo aneurysm. Mr Shaw was successfully treated with a compression bandage and an injection of thrombin into the pseudoaneurysm. By 2 October 2008 the haematoma had completely disappeared.
Around 3.30am on Monday 10 November 2008, Mr Shaw again fell in his bedroom. He was found on the floor by nursing staff with a laceration to his forehead and a skin tear to his right hand. His injuries were attended to and he was assisted back to bed by staff. According to Registered Nurse Michael Smith (Nurse Smith), he conducted a full set of neurological observations and commenced an observations chart. Nurse Smith continued to assess Mr Shaw every half hour following the initial incident until the conclusion of his shift at 7am. At this time Nurse Smith did a full hand over to day shift staff. It is the evidence of Nurse Smith that his handover procedure included placing the neurological observations chart for Mr Shaw into the handover folder although the delivery nurse did not continue the regular observation of Mr Shaw.
Later in the morning Mr Shaw went about his usual routine of being helped out of bed and given breakfast and mobilised.
Around 11am Mr Shaw developed a decreased conscious state. According to the medical records from Strathaven a neurological observation chart was commenced at this time. At 2pm he was transported by ambulance to the Department of Emergency at the RHH.
At the hospital a CT scan of Mr Shaw’s brain revealed a ‘Large right subdural haematoma with associated midline shift and falcine herniation’. Due to Mr Shaw’s premorbid function a decision was made by staff in the emergency department that surgical intervention would not be appropriate. This was also discussed with his daughter who was in agreement. Mr Shaw was kept comfortable and palliative care measures were instituted.
Mr Shaw was reviewed by the Medical Registrar at 8.30pm at which time he was deeply comatose. His case was again discussed with his daughter and it was agreed that he should not be for active medical or surgical management. His comfort measures were continued.
At 6.30pm on 12 November 2008 Mr Shaw died.
An external post mortem examination and review of medical documentation was conducted by Forensic Pathologist, Doctor Christopher Lawrence. He determined that the cause of Mr Shaw’s death was a subdural haematoma following a fall due to Parkinsonism and dementia.
Dr Lawrence made the following comments:
‘Examination of the body reveals bruising on the forehead which would be consistent with occurring on the 10 November 2008. There is some bruising on the forearms and on the right knee which would be consistent with a fall. There are no suspicious signs amongst the injuries and they appear to be consistent with the history’.
Toxicology testing of an ante mortem blood sample taken on 10 November 2008 at the RHH revealed a therapeutic level of the antidepressant drug sertraline.
Comments and Recommendations :
I am satisfied that a thorough and detailed investigation has been carried out into the death of Mr Shaw and that there are no suspicious circumstances.
I accept the opinion of Dr Lawrence and find that Mr Shaw died from the subdural haematoma as a result of a fall due to Parkinsonism and dementia.
Mr Shaw’s family have raised a number of concerns relating to the general lack of care and treatment provided by Strathaven which do no relate specifically to the cause of death. I consider that the issues raised by the family are not within jurisdictional function of the coroner, rather it is my view that they should be referred to the Aged Care Commissioner or the Tasmanian Health Complaints Commissioner.
There certainly appears to be evidence of less than optimum treatment afforded to Mr Shaw by staff at Strathaven after his fall on 10 November 2008. There is evidence that following his fall Mr Shaw received less than optimum treatment in that there is evidence from the attending nurses to the effect that:
Following his fall on the 10 November 2008 Mr Shaw received 15 minutes checks until 7AM but there is no evidence that he received 15 minutes checks thereafter,
That it is practice following a fall for a patient to be observed at 15 minute intervals for 4 hours following the fall.
The evidence suggests that Mr Shaw was not so observed.
I am unable to say whether or not the failure to monitor Mr Shaw more closely in accordance with the standard practice i.e. to keep him under 15 minute observations until at least 7.35AM and under less strict observation thereafter failure to monitor Mr Shaw closer could not have assisted his situation.
The evidence of the nurses as to transfer of the care of a patient under observation shows shortcomings in the system. It is recommended that in such cases the relief nurse should sign an acknowledgement of receipt of the instructions as to the care of a patient which are out of the ordinary to ensure that the relief nurse is specifically advised of any specific problems and so that there is evidence that the relief nurse was actually advised of those problems.
I find that the care and treatment afforded to Mr Shaw at the RHH to be appropriate in all the circumstances.
I wish to conclude by conveying my sincere condolences to the family of Mr Shaw.
DATED: Monday, 13 September 2010 at Hobart in the State of Tasmania.