An inquest verdict of misadventure has been recorded into the death of a 95-year-old man who suffered a bleed to his brain after falling from a hospital bed.
A sitting of Dublin District Coroner’s Court heard on Monday that Denis Keane was discovered on the floor by nursing staff after an unwitnessed fall at Tallaght University Hospital.
Mr Keane from Walkinstown, Co Dublin, had been admitted in March 2023 with decreased mobility and an acute fibula fracture.
Staff nurse Sarah Kelly, who was on duty and caring for Mr Keane on the date of the fall, said a call bell had been given to the 95-year-old as he had a history of falls at home.
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Ms Kelly maintained in her deposition that the bed rails had been raised at the time, adding that Mr Keane was observed throughout the night.
At about 5.45am on April 5th, Mr Keane was found on the floor while the right bed rail was down. A hoist was used to return him to bed.
Mr Keane denied any pain and was unsure how long he had been on the floor, she said, adding that he was routinely observed thereafter.
Dr Sarah Coveney, a consultant in age-related healthcare, said a CT brain scan was booked given the unwitnessed nature of the fall, his ongoing confusion and in light of the dual antiplatelet therapy he was receiving.
The inquest heard the antiplatelet therapy carried an increased risk of an “extensive bleed” following the fall, which was ultimately noted as a contributory factor to his death.
Following his deterioration in the hours following the fall, an urgent CT brain scan was performed which showed a large subdural bleed.
Potential surgical intervention was deemed to be “futile” largely due to his co-morbidities and the extent of the haemorrhage and Mr Keane died on the morning of April 6th.
Mr Keane’s children questioned how the bed rail became lowered, with his daughter Noreen saying her father would have been unable to lower it himself.
“The fact that he fell out of the bed is something that keeps us up at night. You’d need to be a contortionist to take it down,” she said.
Recording an “appropriate” verdict of misadventure, coroner Aisling Gannon said it appeared that the bed rail was down despite being intended to be up.
While the verdict does not infer blame, it does infer there were unintended consequences of an intended act, she said.
“The intended act being the cot rail should have been up in order to avoid the consequences,” being Mr Keane’s fall from the bed, she said.
Mr Keane’s medical cause of death was recorded as a subdural haematoma with midline shift and herniation due to the fall.
