Nursing home resident (104) dies after fall from bed hoist
Published 13/04/2010 | 05:00
DOCTORS did not realise that a 104-year-old woman sustained fatal injuries after a hoist being used to lift her had failed.
Mary Tobin, care of Belvilla Nursing Home, South Circular Road, Dublin 8, broke three ribs and her left collarbone in the fall on January 24 last year.
The sling was not appropriately secured before the hoist was operated. It was being used to lift the elderly woman from her bed to a chair, an inquest at Dublin City Coroner's Court heard yesterday.
An inappropriate size sling was used and both of its lower straps were incorrectly attached to the hoist.
Ms Tobin fell three to four feet and was brought to St James's Hospital where she was examined -- but the fatal injuries were not identified.
The woman -- who was unable to talk after suffering a stroke -- was treated for a head injury and had been cleared for discharge when she collapsed and died suddenly.
A post mortem found she died from cardio-respiratory arrest, blood loss and multiple bone fractures.
Coroner Brian Farrell said he would record a verdict of death by misadventure because of a number of risk factors.
The risk factors included that the sling was not appropriately secured to a bar on the hoist; the inappropriate size of the sling used; the failure of the hoisting operation; that the fatal injuries were not identified at the hospital; and the age of the deceased.
He also raised the issue of communication between staff at the nursing home and the hospital.
Dublin City Coroner's Court heard that two nurses at the home, Sheila Lawlor and Maureen Iboko, were moving Ms Tobin when one side of the hoist gave way. Just one nurse was standing beside the hoist at the time.
"We want to apologise to the family," said director of nursing at the home, Judy Vahey, yesterday. "We've taken every measure we can to prevent anything like this happening again."
Ms Vahey said both nurses had undertaken manual handling training on two dates in 2008 and were familiar with the use of the particular hoist. Since the incident, members of staff are trained in the use of specific hoists and slings, the inquest was told.
Giving evidence, A&E consultant at the hospital, Patrick Plunkett, who did not see Ms Tobin, said that, upon arrival at St James's, doctors were told she had fallen from a hoist approximately two feet from the ground and had banged her head.
The woman was examined by a senior registrar, a laceration on the back of her head was sutured, and a CAT scan of her brain was conducted which showed no injury.
Mr Plunkett said the focus was on a head injury and not the possibility she might have rib fractures. He said they "couldn't have prevented it" even if they had diagnosed the fractures.
He said it was a "sudden, unexpected death" and that the amount of bleeding from three fractured ribs and a fractured collarbone would not be expected to cause someone's death.
"I think we're dealing with very unusual circumstances.
"We very rarely get people of such an advanced age," he told the court.
Counsel for the family said they were not satisfied with the way elderly patients are treated at St James's Hospital and said they wanted to voice that concern.
The coroner said he would write to the hospital on the matter.