The Tauranga Hospital will introduce a new system over the next few weeks to reduce the likelihood of falls by patients.
The move comes after Tauranga coroner Michael Cooney's call for a review of nursing practice at the hospital following the deaths of two elderly patients.
He has also asked for a
further review in 12 months.
Tauranga Hospital manager Alan Wilson said yesterday that the new system would identify patients at risk and ensure staff were aware of the requirements of individual patients.
The improvements would include fall warning signs being placed at the bedsides of elderly patients.
Mr Wilson said patient falls were a major risk in hospitals.
Mr Cooney recommended 12 areas for improvement, including patient assessment, logging of incidents and recording shift handover notes.
In June he called for a review of nursing practice at Tauranga Hospital after two elderly patients died following falls.
Yesterday he found that Margaret Hazel Black, aged 76, died on May 16 of a subdural haematoma after a fall in the hospital.
The inquest heard that Mrs Black was admitted on May 2 with bronchial pneumonia.
By May 13, when Mrs Black fell while in a toilet cubicle, she was recovering from the pneumonia and was able to move around by herself.
Senior clinician Dr Graeme Porter said he was considering discharging her.
The fall at 12.30 pm on May 13 was not witnessed and Mrs Black was found by nursing staff about 10 minutes after it happened.
She told nurses she had hit her head but there was no visible head injury or bruising.
Her blood pressure and pulse were steady and she was seen by a doctor.
The next day she complained of a bad headache and was given paracetamol. A CT scan that evening revealed two 10cm subdural haematomas. She died early on May 16.
The inquest was told Mrs Black was wearing socks when she fell, despite nursing staff warning her not to. The "non-slip" mats in the toilet had recently been mopped.
Dr Porter said Mrs Black was also being treated with anticoagulants because of a heart condition. This was a contributing factor to her death, with anti-coagulant preventing blood clotting normally.
He said diagnosing a subdural haematoma was difficult because of the insidious way it presented itself.
Questioned by the Black family's counsel, Sharon Stewart, Dr Porter said he did not know it was Mrs Black's third fall during her stay.
But if he had, he would not have changed her management plan.
Mr Cooney said there were an average 34 patient falls a month at Tauranga Hospital.
He said there were 70 patient falls a month at Auckland Hospital.
- NZPA
The Tauranga Hospital will introduce a new system over the next few weeks to reduce the likelihood of falls by patients.
The move comes after Tauranga coroner Michael Cooney's call for a review of nursing practice at the hospital following the deaths of two elderly patients.
He has also asked for a
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