Coroner's Finding: Rickard-Simms, Adrienne Rosemary

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Record of Investigation into Death (Without Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Leigh Mackey, Coroner, having investigated the death of Adrienne Rosemary RickardSimms Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is Adrienne Rosemary Rickard-Simms. Mrs Rickard-Simms was 75 (date of birth 31/10/1946) when she died. She was born in New Zealand and lived the majority of her life there with her husband. Five years prior to her death she and her husband migrated to Australia and settled in Tasmania. Due to her declining health and increasing care needs she moved to Rosary Gardens Southern Cross Care (RACF) in August 2021; b) Mrs Rickard-Simms had a number of health concerns leading up to her death including chronic kidney disease (stage 5), for which she was receiving regular dialysis, anemia, hypertension, dyslipidaemia, anxiety and gastroesophageal reflux. On arrival at the RACF she was noted to be reliant on a 4 wheeled walker for mobilisation in and outside of her room. At times, for example when accessing her three times a week dialysis treatments she was taken by her husband in a wheelchair. The RACF notes identified that occaisonally Mrs Rickard-Simms’ mobility became more impaired due to the impacts on her of dialysis and medication.

Mrs Rickard-Simms was assessed by the RACF as being at high risk of falls. She had a history of falling, impaired mobility, vision and hearing deficits and was impulsive, refusing at times, to wait for assistance from staff. Her risk of falls was regularly assessed by the RACF and modifications put in place to reduce her risk. Those modifications included provision of a call bell pendant, encouragment for Mrs Rickard-Simms to use it to call staff and to wait for their assistance before mobilising, ensuring her room was clean and clutter free and that her mobility aid was within her reach.

On 4 May 2022 and following a short hospital stay Mrs Rickard-Simms was assessed by the RACF physiotherapist as remaining a high falls risk and requiring physical assistance with mobility.

On 17 July 2022 the RACF records reflect that Mrs Rickard-Simms had elevated blood pressure, on 18 July 2022 increased confusion was documented and on 19 July 2022 she refused to attend for dialysis as she was feeling unwell and “wobbly”. A further falls risk assessment was undertaken on 22 July 2022 by the RACF Registered Nurse who noted a recent change in functional status and/or medications affecting safe mobiltiy dizziness/postural hypotension, she remained a high risk of falls and age related vision and hearing impairments made it difficult for her to find her way round. Mrs Rickard-Simms’ propensity to be impulsive with her mobility and to not wait for staff to assist, attempting to walk unassisted, were noted. Intervention strategies were recommended.

On the same day as that assessment, 22 July 2022, Mrs Rickard-Simms fell in her room at 1.00pm. She was found behind her door. She reported that she had fallen as she walked toward her door due to a loss of balance. She was assessed as having severe pain to the left hip and leg and was subsequently transferred by Tasmanian Ambulance to the Royal Hobart Hospital (RHH). At the RHH investigations confirmed that Mrs Rickard-Simms had suffered a transcervical neck of femur fracture with mild anterior superior displacement and angulation of the femoral shaft. Dialysis was provided on 23 July 2022 and a hemiarthroplasty performed on 24 July 2022.

Post operatively Mrs Rickard-Simms suffered delirium, sepsis and encephalopathy. A Medical Emergency Team (MET) call was made on 25 July 2022 at 9.55am due to her decreased consciousness and twitching movements.

A further MET call was made at 4.30pm the same day again due to decreased consciousness.

There were no improvements in Mrs Rickard-Simms’ condition and in concert with discussions with her family her goals of care were changed to comfort care and she was transferred to the Whittle Ward for palliation where she died on 1 August 2022.

c) Mrs Rickard-Simms’ cause of death was postoperative delirium/exacerbation of community acquired pneumonia following a left hip bipolar hemiarthroplasty undertaken to surgically fix a neck of femur fracture which had resulted from her fall at the RACF; and d) Mrs Rickard-Simms died on 1 August 2022 at Hobart, Tasmania.

In making the above findings I have had regard to the evidence gained in the comprehensive investigation into Mrs Rickard-Simms’ death. The evidence includes the:

• Police report of death

• Hospital report of death

• An opinion of the forensic pathologist;

• Police and ID affidavits;

• Medical records of the RHH, RACF and General Practitioner including a response to the coroner’s falls questionnaire by the RACF and;

• Report of Dr Anthony Bell, medical advisor to the coroner.

Comments and recommendations The circumstances of Mrs Rickard-Simms’ death are not such as to require me to make any comments or recommendations pursuant to Section 28 of the Coroners Act 1995.

I have been assisted in making these findings by the information provided by the RACF and the report of Dr Anthony Bell. I note that Mrs Rickard-Simms was a high fall risk and had been assessed as such appropriately by the RACF. Suitable moderations and adjustments to her living environment had been made to accommodate that risk. Mrs Rickard-Simms was known to be non-compliant with requests for her to call for and await assistance before mobilising. This is reflected in the fact that in the three months leading up to the fracture of her femur and RHH admission she had fallen five times. I find that nothing else could have been done by the RACF to avoid the risk of falls to Mrs Rickard-Simms that would not have unreasonably impinged upon her independence and quality of life.

I convey my sincere condolences to the family and loved ones of Mrs Rickard-Simms.

Dated: 14 January 2025 at Hobart Coroners Court in the State of Tasmania.

Leigh Mackey Coroner