An inquest into the death of a patient who fell in Royal Darwin Hospital emergency ward found overcrowding played a part in his death. Kerry Murphy, 73, fell on his way to the Emergency Department bathroom in July 2014, where he was being treated because every other bed in the hospital was full. Mr Murphy, a retired dairy farmer, lumberjack and soldier was admitted after a dizzy spell at home and was being treated for pneumonia. The inquest heard Mr Murphy was “double bunked” in an “overcrowded” Emergency Department, where nurses were dealing with more patients than usual. Coroner Greg Cavanagh said without the overcrowding Mr Murphy would most likely have been placed on a ward. “Over-crowding of the hospital during that time was obviously a contributor to the fall,” he said. “But for overcrowding he would have likely been on the medical ward and assessed for his falls risk and the appropriate mitigation strategies put in place.” The inquest heard RDH had since implemented a falls risk policy and increased capacity in its emergency department by 13 beds a day. Coroner Greg Cavanagh recommended in his findings that RDH continue to review its falls policy and improve communication between medical staff at shift changes. “I therefore recommend that Royal Darwin Hospital ensure through continued education and audit that the Falls Risk Policy is appropriately used in the Emergency Department,”’ he said. “I also recommend that handovers (both nursing and medical) and transfers to Darwin Private Hospital continue to be audited to ensure those systems are functioning in the intended manner. “ Mr Cavanagh said RDH had indicated changes had been put in place to address the issues outlined in the inquest. “In this case the Royal Darwin Hospital has presented significant evidence that they have made or were making changes to their policies, processes and procedures to ensure that the failures identified were less likely to reoccur in the future. “Those changes however were not well embedded into the hospital systems by the date of hearing.
