Coroner Report – what can we learn! A recent report from Victoria has called for better training of staff following the death of a resident who had had repeated falls.  The Coroner found the man’s records were ‘sub-optimal’ and created ‘confusion and mistrust’.

The notes from the facility recorded the two most recent falls directly before his death but they were not recorded in chronological order and there were gaps of several hours on the day prior to his death.  One note recorded “was slightly confused and very drowsy” but this was crossed out and replaced with “resident had a good breakfast, all his medication and shower“.

Following this resident’s transfer to hospital it was found that he had a haematoma to the base of his skull.  The Coroner stated that once his decline was apparent the actions taken were appropriate but that she was unable to conclude that earlier medical intervention would have led to a different outcome.

The moral of the story is that all staff must ensure that their protocols are followed in regard to observing a resident following a fall, that notes are recorded accurately, in a timely fashion and consecutively.  Not to do so exposes organisations and individuals to significant risk.

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