Coronial inquest to examine night of Judith Flynn’s death after Canberra Hospital fall

A Canberra Hospital nurse has told a coronial inquest she heard a “bang”, before finding an elderly patient on the floor beside her bed with catastrophic head injuries.

Judith Gaye Flynn, 72, died after falling in one of hospital’s wards and hitting her head in 2019, six days after being admitted for a separate incident.

The ACT Coroner’s Court is examining whether Mrs Flynn received adequate supervision during her stay, as well as the circumstances surrounding her death.

Her family said Mrs Flynn was greatly missed, and that they thought she would “be safe” at the hospital.

Death ‘preventable’, family say

Mrs Flynn was admitted to Canberra Hospital after a fall at an aged care facility in January 2019.

Four days later, while a patient on one of the wards, she fell and hit her head, causing fatal injuries. 

“We knew our Mum was confused, disoriented and highly vulnerable,” Mrs Flynn’s daughter Jo Lane said.

“We thought she would receive the care she needed and be safe at The Canberra Hospital.”

Ms Lane said she hoped the inquest into her mother’s death would establish protocols to better protect vulnerable and elderly patients.

“Our Mum’s death was preventable and we would not want anyone else or their loved ones to go through the horrendous experience that we did,” she said.

The nurse who cared for Mrs Flynn at the time of her fall told the inquest during its first hearing yesterday that she noticed Mrs Flynn’s condition deteriorate after she arrived at hospital.

She said Mrs Flynn could respond to instructions, but she seemed unable to follow directions, including a suggestion to ring the bell if she needed something.

The nurse told the inquest she asked her supervisor to move Mrs Flynn to a room closer to the nurses’ station so she could be more closely monitored, but the room was occupied by someone waiting to be discharged and it never eventuated.

Extra staff member not rostered, inquest hears

The court heard Mrs Flynn left her room on her own several times, without using her walker, instead clinging to the wall rail, and had to be taken back to bed.

The inquest was told the nurse left Mrs Flynn for a moment to get something when she fell.

The nurse also said when there was an elderly patient with high needs like Mrs Flynn, an extra staff member was rostered on to help, but this had not happened.

The counsel assisting the coroner, Ken Archer, said the inquest would look into what guidelines were given to staff about care for elderly and vulnerable patients, and what changes had since been implemented.

Mr Archer told the court the ACT government had only recently provided statements from those who were caring for Mrs Flynn.

He said her family had many questions about the circumstances of her death, including the hospital’s assessment of her condition when she was admitted.

“Were adequate steps taken to diagnose the cognitive impairment on delirium she was experiencing when admitted?” Mr Archer asked the court.

He also queried whether that could have had an influence on her care.

The hearing will likely run into next year.