Case 17918 (Community setting)

The faller, a 72 year old right handed male fell on the driveway of his house on July 25, 2012 at approximately 14:15. This was the second fall resulting in serious head injury that this person experienced since the beginning of 2012. Both falls led the faller to seek medical attention in the emergency room and admission to the hospital. On the day of the fall, the faller had an uneventful morning consisting of normal activities such as eating breakfast and resting on the couch. In the afternoon, the faller accompanied his wife to her mammogram appointment and later to the butcher shop. When they returned home after their busy afternoon, the faller’s wife was getting grocery bags out of the trunk of the car when she noticed her husband walking down their driveway, towards the mailboxes situated across the street. She warned the faller not to pick up the mail and that she would go herself later, but he did not listen. After some bickering, the faller rushed towards the mailbox, confident that he was capable of performing such a simple task. He took 5-6 steps on the cobblestone driveway using his cane, then switched his cane from his right hand to his left hand so that his right hand was free to reach into his right pant pocket for the mailbox key. As he was performing these tasks, the faller lost his footing and consequently lost his balance. He fell forward and landed on the ground on his left side. The impact of the fall caused the faller’s glasses to break and the metal frame to cut

the skin near his left eyebrow. The sound of the impact and the sight of blood scared the faller’s wife, and she rushed towards him, dropping everything on her way. She shook the faller to make sure he was breathing and yelled for help. A nearby neighbor heard the commotion and rushed outside to assist. She called an ambulance and within a couple of minutes the paramedics arrived at the scene and transported the faller to the emergency room. The faller did not report losing consciousness, but he was hospitalized for 2 days. This fall resulted in a new small right tentorial smear subdural hematoma, and the faller received two sutures for his eyebrow laceration.

Multiple contributing factors were identified for this event and included deficiencies within all four levels of the Swiss Cheese Model of Accident Causation. These are discussed below:

• The faller experienced frequent falls, two of which resulted in subdural

hematomas and required hospitalizations. He had muscle weakness, osteoarthritis, Type 2 Diabetes, Alzheimer’s disease, seizures, and chronic insomnia

accompanied by daytime fatigue. Due to these reasons, the faller’s wife never left the faller unsupervised and had to take him with her when she ran errands or went to her own medical appointments.

• The faller suffered from chronic insomnia and often felt fatigued. On the day of the fall, the faller had been out with his wife all afternoon, accompanying her to her mammogram appointment and also to the butcher shop. He had not slept well the night before and was tired. Several hours had passed since he last ate, and although his exact blood-glucose levels at the time of the fall are not known, his hunger may have added to his fatigue.

• The faller often did not listen to his wife’s instructions and was overconfident in his abilities to complete tasks that he used to do independently. The faller and his wife argued and bickered often, and at the time of the fall, he was in a hurry to prove to his wife that he was still capable of picking up the mail by himself.

• The PT at the hospital recommended a rollater walker for outdoor use, but the faller did not use his walker and instead used a cane. For him, the walker was inconvenient and the cane was easier to use. He needed his cane for support at all times. At the time of the fall, he was using his cane but had switched it from his right to left hand so that he could reach into his right pant pocket to get his mailbox key. Therefore, at the time of the fall, he did not have the support of his cane.

• The central mailbox unit, where all mailboxes for the 20 townhomes on the street, was located 25 meters away from the faller’s driveway. This posed a problem for both the faller and his wife, because both suffered from arthritis and because the faller was unsteady on his feet. It was a long distance to walk to retrieve their mail.

• After his first fall and subsequent long hospitalization period, the faller was discharged home with minimal CCAC support. Because the faller’s neurological capacity had returned back to baseline, he was deemed eligible to go back home in the care of his wife.

• CCAC provided the faller with three PT and three OT sessions. A home

assessment was done and recommendations regarding bathroom grab bars were made. Dressing and showering services were refused because the faller and his wife felt more comfortable doing these themselves.

• The faller and his wife had no children or relatives, and the faller’s wife was the sole caregiver for the faller. She suffered from many chronic health conditions herself, including breast cancer and arthritis. She was stressed and tired with her increasing responsibilities caring for her husband and herself, as well as taking care of the home and finances. She was in need of respite care. However, the faller was only provided with a half-day adult day program by the CCAC, once a week. This was the only time the faller’s wife was away from the faller. She did not think a nursing home was a viable option but acknowledged that she needed help and support in caring for her husband.

• When the faller’s wife requested house cleaning support from the CCAC they refused because they no longer provided these services due to budget cutbacks. They provided the faller’s wife with a list of vendors who offered cleaning services. These services had to be paid for out-of-pocket by the faller and his wife.

• The faller’s wife felt dissatisfied with the level of support she was receiving from the CCAC but was reluctant to share this information because she feared that they would be cut off from all services if she said anything negative.