Put 'at risk' patients in non-slip socks - coroner
A coroner has recommended rest home patients at risk of falling wear non-slip footwear, after the death of a 91-year-old woman in Greymouth.
Frances Ellen Watson died of a heart attack in Greymouth's Richard Seddon Hospital in December 2010, several hours after a fall, Coroner Richard McElrea ruled in a decision released today.
At about 2am on December 13 Watson was found lying on the floor of her bedroom ensuite by a newly-graduated registered nurse. She was given a physical assessment by the registered nurse and two experienced enrolled nurses before being put back in bed and given pain relief.
During subsequent checks the 91-year-old appeared settled, but at 4am she called for a nurse who administered oxygen and codeine, the report said.
By 5.45am Watson had become unwell again and told staff that she wanted to see her daughter, who arrived a short time later and stayed with Watson until she died at 9.45am.
In a statement to police, the daughter Ann Blacktopp said her mother was lying with one leg "in an odd position ... almost like she had broken her hip".
An attending locum issued a medical certificate, but Dr Anna Dyzel from Hokitika raised concerns with the coroner leading to the inquiry.
An autopsy confirmed death was due to a heart attack, but pathologist Dr Martin Sage noted a recent hip fracture as a complicating factor.
The nurse manager at the time raised concerns that Watson should have been referred to Grey Base Hospital following the fall, but Coroner McElrea concluded that the non-referral would not have made any difference to the outcome.
He said inappropriate footwear could have contributed to Watson's fall, as she was only wearing socks at the time.
He recommended the rest home alter its policies so patients with a history of falls wore appropriate footwear, such as non-slip socks.
In her statement to police, Blacktopp said her mother had been well looked after during her years in the facility.
"She had suffered major illnesses, coped with them bravely and gratefully paid for her security and comfort which her precarious health demanded," Blacktopp said.