Ms SME died on 21 January 2016 at the age of 86 years at an Aged Care facility. At the time of her death, Ms SME was receiving ongoing palliative care at the Aged Care facility. Two weeks before her death, Ms SME suffered a fall during a sponge bath for which she required hospitalisation.

The Incident Analysis Report found the cause of death was subdural haemorrhage caused by the fall. The Coroner held that given the Aged Care facility had implemented recommendations made subsequent to Ms SME's death, a coronial inquest was not in the public's interest.

Background Facts

Ms SME resided at an Aged Care facility in Brisbane. On 18 January 2016, Ms SME fell out of bed whilst receiving a sponge bath by two carers.

One carer, Ms VD decided that as Ms SME was in the middle of her bed on her back there was no requirement to reposition her with a slide sheet prior to her sponge bath. After Ms SME's upper body had been washed, two carers (including Ms VD) prepared to roll Ms SME. Both carers appropriately rolled Ms SME on to her right side. Ms VD proceeded to ask the other carer, Ms TA, if she was all right and removed her hand from supporting Ms SME, to turn to retrieve a bowl from Ms SME's bedside. As Ms VD turned her back, Ms SME fell towards Ms TA, landing on the floor on her left hand side. Ms SME was bleeding heavily from her head.

Following the fall, Ms SME was admitted to Logan Hospital for observation and conservative treatment. A CT scan of Ms SME's brain showed the presence of a subdural haemorrhage. Due to the patient's age and morbidity it was agreed that Ms SME was to receive palliative treatment at the Aged Care facility. She was subsequently discharged from the hospital. Ms SME returned to the Aged Care facility on 20 January 2016 and passed away the following day.

Ms SME's son, Mr PE, expressed numerous concerns to the Department of Health and Aging (DOHA) and the Office of Health Ombudsman (OHO) pertaining to his mother's fall. He expressed concerns in relation to the inadequacies of his mother’s care, including care not being provided in accordance to the care plan and staff being ill equipped in the use of the stand-up hoist. He complained to the OHO that his mother had been “dropped” by staff.


The Incident Analysis Report (report) found that the cause of the patient's fall may have been an incomplete repositioning of the resident in the middle of the bed without the use of a slide sheet before facilitating the roll. The Coroner found the cause of death was subdural haemorrhage, due to or as a consequence of the fall.

Having regard to the investigations into the cause of death and recommendations made and implemented, the Coroner concluded that it was not in the public interest to proceed to inquest.


Based on the report four recommendations were made to the Aged Care facility, following the death of Ms SME.

The recommendations included:

  1. all staff undertake manual handling training including the appropriate use of slide sheets. This is to include training on position of residents in bed, angle and height of bed;
  2. safety observations are to be undertaken by registered nurses throughout shifts, ensuring staff are using slide sheets appropriately;
  3. all staff will receive further training on the CP22 and mobility care plans; and
  4. training is to be provided to all staff on the use of the call bell, specifically the call bell and response expectations.

These recommendations were implemented by the Aged Care facility.


The coroner's court of Queensland found that having regard to the cause of death and recommendations made and subsequently implemented, there was no need for an inquest.