Coroner's Finding: Colpo, Dario

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Record of Investigation into Death (Without Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Robert Webster, Coroner, having investigated the death of Dario Colpo Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is Dario Colpo (“Mr Colpo”); b) Mr Colpo died from complications arising from a fall which occurred at a Residential Aged Care Facility (RACF); c) Mr Colpo’s cause of death was a left haemothorax and rib fractures resulting from the fall and the development of pneumonia; and d) Mr Colpo died on 30 May 2021 at Launceston in Tasmania.

In making the above findings I have had regard to the evidence gained in the investigation into Mr Colpo’s death. The evidence includes:  Police Report of Death for the Coroner;  Affidavits establishing identity and life extinct;  Tasmanian Health Service Death Report to Coroner;  Report of Dr Christopher Lawrence, Forensic Pathologist;  Affidavit of, and email from, Mr John Colpo;  Affidavit of Ms Giuliana Murfet;  Medical records obtained from the Northern Suburbs Medical Service;  Medical records obtained from the Tasmanian Health Service (THS);  Records obtained from the RACF; and  Report of the coronial nursing consultant Libby Newman RN.

Background Mr Colpo was born on 26 February 1929 and was 92 years of age at the date of his death.

He was born in Vicenza, Italy to his parents Giovanni Colpo and Maria Cecchinato. He had

five siblings and grew up in Vicenza before moving to Australia in 1951. He returned to Italy in 1959 before coming back to Australia in 1969.

He married Gabriella Minicelli in 1969 and had five children. Mr Colpo obtained an education which was equivalent to TAFE level and he became a machinist.

Mr Colpo was a social drinker and drank alcohol daily however his consumption of alcohol was less regular in his later years. He smoked until his early 40s at which time he ceased smoking.

Health Mr John Colpo says he was aware his father had an enlarged heart, type II diabetes, regular fluid in the lungs and poor circulation. He may have had other medical conditions. He is aware his father had a heart attack at 28 years of age, he had decreased lung capacity and occasionally contracted gout. He would often cease taking his medication for the fluid buildup and every 6 to 12 months his family would find him collapsed on the floor after which he would require medical treatment.

Mr John Colpo says his father had been unwell for quite a few years and was a “serial falls risk”. He would often not protect himself when he fell and would often require hospitalisation.

Mr Colpo entered the Japara RACF at Riverside in February 2021 after a serious fall. He had hit the handle of his oven and severely lacerated his head. This required a hospital visit during which he was convinced by his family to enter respite for a few weeks after which he was convinced to remain at the RACF.

After Mr Colpo was placed in the RACF the family and the home implemented a number of strategies because it was believed Mr Colpo was at a high risk of falling. These strategies included lowering his bed, placing alarm mats in his room to call staff when he arose and the like.

The medical records confirm Mr Colpo injured his head on the oven and was taken to the Launceston General Hospital (LGH) for treatment of his injuries on 29 January 2021. The notes confirm admission to the RACF for respite in early February 2021 during which time he had difficulties with cellulitis first in his right lower leg and then in his left lower leg which condition was treated. The GP notes on 8 May 2021 show Mr Colpo had a fall a few days earlier where he had bruised his right arm and thigh but otherwise he was fine. He was seen walking with his four wheel walker. He had persistent swelling of both legs.

Circumstances Leading to Mr Colpo’s Death The records of the LGH confirm an admission between 12 and 30 May 2021 as a result of injuries sustained in a fall on 12 May 2021. Mr Colpo had a history of falls. He was brought in by ambulance. CT scans showed a left haemothorax1 and rib fractures and a CT of the brain showed no abnormalities.

An x-ray of the chest on 21 May 2021 showed cardiomegaly and left lower lobe consolidation and congested lungs. When compared to the previous study the left lower lobe consolidation and left-sided pleural effusion/haemothorax appeared to have increased.

A CT pulmonary angiogram of 24 May 2021 showed no evidence of pulmonary embolism or pneumonia but did show moderate bilateral pleural effusions with compressive atelectasis of the left lower lobe.

The notes indicate the family were advised there was no thoracic unit at the LGH so if Mr Colpo required surgical intervention he would need to go to Hobart but the best course of action may not involve an operation. One of his daughters agreed and said Mr Colpo would not want to be resuscitated. She was agreeable to full ward management and a chest tube plus supportive care and if he went on to develop active bleeding or if he deteriorated they would discuss comfort care. Mr Colpo was provided with opioids and regular paracetamol however he became increasingly drowsy and opioids were ceased. Good pain control was then achieved with an erector spinal catheter. Mr Colpo also experienced tachypnoea2 in the context of cardiac and respiratory history and delirium. He had a number of medical emergency team (MET) calls due to the tachypnoea which was likely secondary to pain. The family had a discussion about nasogastric tube feeding due to concerns with respect to invasive management. He became agitated confused and was given medication to settle him. Once his intercostal catheter was removed he developed tachypnoea and he desaturated.3 Mr Colpo’s condition slowly deteriorated over the ensuing days and he developed pneumonia. On 30 May 2021 at 1.40pm he was being placed in a hoist to be moved from a chair to his bed. While being placed in the hoist he appeared to pass out and a call was 1 Bleeding within the pleural cavity.

2 Abnormally rapid breathing.

3 Respiratory desaturation is when the amount of oxygen bound in a person’s haemoglobin drops below the normal level. Any condition that disrupts the body's ability to deliver adequate oxygen to the blood can cause respiratory desaturation. This can vary from mild to life-threatening depending on how low the levels drop.

made. The treating doctor entered the room approximately 30 seconds later and were taking Mr Colpo’s observations when he passed away.

Investigation Mr John Colpo says in his affidavit that he and his family have no issues with his father’s medical treatment or the treatment he received at the nursing home prior to his passing.

Mr Colpo says he feels both organisations sufficiently attended to his father’s needs. He indicated his father did not complain about how he was treated and he himself did not feel “that there is culpability due to all the methods we put in place to protect him.” As is the family’s right a post-mortem was subject to an objection. The affidavit of Ms Murfet, one of Mr Colpo’s daughters, says during the admission to the LGH her father had multiple MET calls where his heart had failed. In more recent times he had only 80% oxygen levels. He had a haemothorax and as result had to be taken off his blood thinners. Therefore she believed it was only a matter of time before clots formed. She says her father is deeply religious and would not have wished for medical intervention and she believed it would distress him greatly if a post-mortem was to occur. She also says such a procedure would cause his family great distress especially given they had anticipated his death. A subsequent email was received from Mr John Colpo indicating Mr Colpo’s family had no objection to a limited non-invasive post-mortem which consisted of a CT scan, a review of hospital records and an external examination.

The forensic pathologist Dr Christopher Lawrence conducted a limited non-invasive postmortem on 1 June 2021. He examined Mr Colpo’s medical records and conducted an external examination. He noted Mr Colpo was prescribed rivaroxaban for atrial fibrillation and that he had chronic obstructive pulmonary disease, congestive cardiac failure, chronic renal failure, hypertension, type II diabetes and was subject to recurrent falls. In this case he had fallen and suffered a left haemothorax and rib fractures and as a result of these injuries he contracted pneumonia which led to his passing. I accept Dr Lawrence’s opinion.

Because the fall which triggered Mr Colpo’s deteriorating condition and subsequent death occurred in a RACF it was arranged for the registered nurse and coronial nursing consultant Ms Newman to examine the records of the RACF.

The records of the RACF reveal Mr Colpo was a 92 year old man who moved into Japara RACF in Riverside in February 2021 as a result of frequent falls and general frailty.

While at the RACF he generally preferred to spend time in his room but he would attend some social events. He continued to fall, however, and had multiple falls following his admission.

Assessment by a physiotherapist a few days after his admission revealed he would become short of breath on exertion and had poor balance – these factors limited his exercise tolerance and mobility in general. Mr Colpo required and used a four wheeled walker (or, early on, a single point walking stick) to mobilise and was assessed as requiring the assistance/supervision of one carer to mobilise and for all transfers. He needed full assistance with all activities of daily living. Cognitively it was thought Mr Colpo was functioning fairly well however he was hard of hearing and English was known to be his second language.

On the same day as the physiotherapist reviewed him, Mr Colpo was found on the floor of his bedroom in the evening. Ambulance Tasmania (AT) attended and transported him to the Launceston General Hospital (LGH). He returned to his nursing home on 10 February 2021 following assessment and investigations which did not show any bony fractures or bleeding.

Mr Colpo went on to have unwitnessed falls on 13 and 20 February 2021. After an assessment it was determined he did not injure himself on these occasions. After the second fall the nursing home notes record contact with Mr Colpo’s family at which time arrangements were made to meet in order to discuss falls prevention strategies.

The physiotherapist reviewed Mr Colpo on 22 February 2021. At this review Mr Colpo said he was frightened to mobilise and he was scared of falling again. The physiotherapist noted he was not wearing non-slip socks and did not appear to have appropriate footwear. It was recommended to care staff they reinforce the use of non-slip socks, and they were to reinforce the use of a call bell so that Mr Colpo sought assistance for mobilising and/or transferring.

Mr Colpo fell again on 24 February 2021. He sustained bruising but no other injuries at this time. The physiotherapist reviewed him on 25 February 2021 and recommended his family ensure they provided him with ‘good well-fitting footwear’ and clothes (his pants were falling down on their assessment this day). The physiotherapist also recommended care staff were to provide assistance with all mobilising and/or transferring, to ensure Mr Colpo wore a belt with his pants and that he wore non-slip socks and/or good footwear at all times when he was out of bed.

Mr Colpo developed cellulitis on both his legs around this time and was prescribed ongoing antibiotics for this as well as some for a case of orbital cellulitis he developed later in March.

In April Mr Colpo would occasionally not want to sleep in his bed as he stated he was frightened of falling out. On these occasions he was made as comfortable as possible in an

armchair in his room. It is unclear from the notes exactly when in April this occurred but it appears sensor mats were installed in his room to alert staff if he was mobilising.

On 12 April 2021 Mr Colpo had another fall when he slipped from his chair. He developed a sore shoulder as a result of this fall. Nursing home notes state he had ‘crash mats’ by his bed. He was reviewed by the physiotherapist on 13 April 2021 and there were no changes made to his mobility plan.

On 16 April 2021 Mr Colpo was seen by a podiatrist and had his nails cut, filed and cleaned.

A plan for him to be reviewed by the podiatrist every six weeks was put into place at this time.

On 17 April 2021 Mr Colpo fell again. Staff found him behind a chair in his bedroom. The notes say: “Dario stated that he was trying to go to toilet and could not move legs and landed on floor. Nil injuries noted. Nil head strike. However, has pain on lower back while getting up….Assisted back to bed using full hoist…Actions taken to prevent future incidents – frequent observations while he is in on [sic] room as sensor mat is broken. Explained Dario to use call bell when he needs to go to bathroom…” A comprehensive physiotherapy assessment/plan was carried out on 21 April 2021. The notes state: “For mobility staff to provide 1 x physical assistance. Dario also requires the use of a 4ww to ensure safety during mobility. Staff member to maintain hands on assistance at all times and provide physical assistance by standing to one side of Dario, with one hand on her [sic] lower back and their other hand on her [sic] shoulder… Walks with wide based gait.

Stoops forward leaning on the 4WW, requires to be prompted to correct his posture while walking to prevent falls…” It was also noted Mr Colpo required the assistance of two care staff for bed mobility.

On 25 April 2021 Mr Colpo declined to sleep in his bed again.

On 2 May 2021 Mr Colpo underwent a cognitive skills assessment which was performed by a registered nurse at the RACF. It was determined he was disoriented to time and when in an unfamiliar place. “He can recall long time past events, however, speaks in his own language.” The assessment concluded he was moderately impaired.

Another comprehensive physiotherapy assessment was performed on 4 May 2021. The outcomes of this assessment were basically the same as the previous assessment however he now required the assistance of two care staff for all transfers.

On the same day Mr Colpo had another unwitnessed fall. The notes indicate he was found at 4.45pm by an extended care assistance (ECA) lying on his back wedged behind the toilet door. There were nil obvious injuries initially but Mr Colpo complained of having a sore shoulder, and then stated that he hit his head on the wall when falling. The incident report for this fall includes the following: “…Apparently the lady attending the kitchen witness [sic] Dario get up and take himself to the toilet independently. When the ECA noticed Dario was not sitting in the dining room she went to investigate where he was….” At this time it was noted Mr Colpo was wearing ‘slides’ when he fell. The notes say “these are inappropriate footwear for walking safely”. In another section of the incident form it states, “Actions taken to prevent future incidents: Dario should wear appropriate shoes to prevent further fall. Family need to be consulted about this matter”. As Mr Colpo took anticoagulant medication a non-urgent ambulance was called to review him (as per protocol at the nursing home). The notes reveal what then transpired: “Resident reviewed by paramedic Jill Finn who found no injuries on her assessment. Jill respects the wishes of Dario and his son John Colpo with whom she spoke after assessing Dario. They do not wish transfer to hospital for imaging and investigations. If any deterioration in condition Tas Ambulance to be contacted immediately. This incident is being treated as an internal critical incident. Family needs to be contacted regarding a conference to document an advanced care plan. Presently there is only a directive for no CPR.

Managers directive is for Dario to be reviewed frequently overnight and have hourly neuro observations done… RN observed very inappropriate footwear are presently being worn which could have contributed to his fall. At this stage aetiology of fall unknown. ATOR Dario sleeping in his armchair…” The physiotherapist reviewed Mr Colpo on 5 May 2021. On 8 May 2021 Mr Colpo’s general practitioner reviewed him – mostly focussing on his legs/skin.

On 12 May 2021 Mr Colpo had another fall. The nursing home notes state, “Dario was found on the floor with bruising in his right leg extending from hip to knee… Dario was found on the bathroom floor with his head close to the wall at glance [sic] it looked like he slip [sic] while trying to get to the toilet… RN perform the head to toe assessment, no external injury noted except bruising in his right leg and on full ROM he was having pain in his right hip, on touching it was hard and was not looking right, so second assessment perform by CCC and decided to call the ambulance…”

On 24 May 2021 the nursing home notes record a family conference with Mr Colpo’s son.

The notes include, “…John also stated that he is going to make Dario’s room more like a home for him and bring in some things from home… No other concerns raised, would just like Dario to continue to be as mobile as possible for as long as possible… Overall happy with the care and support staff have provided to Dario and John”.

The most recent falls risk assessment prior to the fall on 12 May 2021 occurred on 24 February 2021 where a score of 24 was returned which indicates ‘significant risk’. This assessment was the most recent one I could see in the notes supplied from the nursing home however as Mr Colpo was regularly reviewed by the physiotherapist after each fall and then at other times (when they conducted their comprehensive assessments) his falls risk was being re-assessed very frequently. His falls risk assessment was therefore, in my view, up to date.

Falls prevention strategies were noted to be as follows: keep pathway clear at all times; ensure lighting is appropriate for the time of day; encourage Mr Colpo to use his four wheel walker at all times; increased general observation levels; suitable footwear; call bell to be within reach; reassurance and encouragement; regular physiotherapist review and six weekly podiatry reviews. In addition to what was noted in one section of the notes it appears ‘crash mats’ were in place in Mr Colpo’s room and possibly a bed sensor was also in place.

Ms Newman says: “Mr Colpo was at high risk of falling as evidenced by the falls he sustained and the assessments undertaken at Japara…. It appears he was not particularly compliant with seeking assistance when he wished to mobilise. His falls all appear to have been unwitnessed. Certainly this makes it very challenging for staff to manage him and keep him safe when he attempted to mobilise or transfer independently.

There are three issues I have with Mr Colpo’s circumstances:

1. It is noted his sensor mat was not working on 17.04.2021 – it would be good to know if this had been fixed/replaced or not (and if not, why not?)

2. There are frequent recommendations from the physiotherapist that Mr Colpo required appropriate footwear and/or non-slip socks. It is unclear how/why he was wearing ‘slides’ on 04.05.2021 when he fell – had he put them on himself and staff were unaware? Did staff not realise this footwear was unsafe? Did his family supply this footwear in the belief it was appropriate?

3. Mr Colpo was known to fall frequently – it is unclear why the kitchen staff member witnessed Mr Colpo mobilising independently but did not notify the care staff of this fact (this is in relation to the fall sustained on 04.05.2021).

Other than these points noted above it appears other falls prevention strategies listed are appropriate and timely and certainly the physiotherapy follow up to falls and their general assessments were excellent.” I accept and agree with the opinions expressed by Ms Newman.

The RACF was given an opportunity to respond to these issues. The Home Manager Sarah Chong responded as follows: “In regards to the 3 comments, I am unable to comment as I started my position at Riverside in July 2021 after Mr Colpo had passed away.” This is obviously a completely inappropriate response given the issues raised by Ms Newman. If the sensor mat was not working, if Mr Colpo was wearing slides and if he was mobilising independently then the risk of a fall and subsequent injury leading to death was significantly increased.

Comments and Recommendations I recommend that in circumstances where a resident has been assessed as requiring a sensor mat, that he or she is to wear appropriate footwear and/or nonslip socks and that he or she is not to mobilise independently, then Japara Riverside Views4 ensure such recommendations are implemented at all times. These recommendations had been made with respect to Mr Colpo however the evidence suggests they were not implemented at all times thereby increasing the risk of falls in a person who was quite properly assessed as a very high falls risk.

The circumstances of Mr Colpo’s death are not such as to require me to make any further comments or recommendations pursuant to Section 28 of the Coroners Act 1995.

I convey my sincere condolences to the family and loved ones of Mr Colpo.

Dated: 7 August 2023 at Hobart in the State of Tasmania.

Robert Webster Coroner 4 This RACF is now known as Calvary Riverside Views. Japara joined Calvary Health Care in November 2021.