The coroner investigating the death of Rosemarie Timer, a woman who died after hitting her head in a fall at Eagle Ridge Hospital in 2014, said she is satisfied that changes have been made to prevent future similar incidents.
B.C. Coroner Service’s Tara Louise Devine said in her report that no recommendations were necessary, noting that improvements to falls-management strategies have been implemented following a Fraser Health Authority review of the incident.
“As there have been implemented recommendations to increase communications between staff members, patients and their families, and to reduce the risk of falls, I classify the death as accidental and make no recommendations,” Devine wrote in her report.
Timer, a 70-year-old cancer patient, was living in an assisted care facility in Port Coquitlam when she was admitted to ERH on April 4. It was found she was suffering from anemia, an elevated white blood cell count and a bacterial infection.
Doctors and her family decided that she would not be able to return to her prior living arrangements and she was expected to stay at the hospital until a long-term care bed came open.
But her condition worsened and, on May 19, 2014, she had her first fall, which was followed by a second, more serious fall on May 28, in which she lacerated the back of her head.
“The laceration was sutured and she initially appeared to be stable,” Devine stated in her report. “CT scan of her head on May 30, 2014, diagnosed subdural hematoma. She was not a surgical candidate and was placed on comfort measures until her death on June 16.”
The cause of death was confirmed by the coroner to be subdural hematoma resulting from the fall.
Following Timer’s death, Devine noted that an internal review was put in place by the Fraser Health Authority. She said that a falls audit was completed and that improved communication between staff members and the families of patients regarding falls management strategies has been effective.
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