Mr George Fenech died on 11 November 2017 at the age of 89 years. An autopsy revealed that Mr Fenech died as a result of congestive heart failure as a consequence of ischaemic cardiomyopathy.

The autopsy also noted that Mr Fenech had a neck injury from a fall and atrial fibrillation. At 2:45am on 9 November 2017, Mr Fenech had been found on the floor of his Nursing Home room with a large head wound. The Coroner closed the investigation without inquest as any concern relating to Mr Fenech's fall and preventative measures to stop similar occurrences had been addressed by the provider and the Aged Care Complaints Commission.

Background Facts

Mr George Fenech lived at TriCare Nursing Home at the time of his death. His past medical history included atrial fibrillation, chronic kidney disease, congestive heart failure, cardiomyopathy, abnormal gait including ataxia and spastic gait and he was unable to grip with his hands.

At 2:10am on 9 November 2017, a carer and Registered Nurse attended Mr Fenech and noted that he was leaning to the left side, incontinent of urine, pale and had slurred speech. By 2:45am, Mr Fenech was found to be on the floor of his room, wedged under the bed by the wardrobe. He had a number of head lacerations, with a suspected arterial bleed and a floating Glasgow Coma Scale around 10-12. It is believed that Mr Fenech fell to the floor from his bed, but there was no witnesses.

Mr Fenech was later transferred to hospital at 5:15am on 9 November 2017. Mr Fenech was treated for a fracture to the C1 and C2 vertebrae and the lacerations to his head. It was well documented by Ms Marea Fenech, Mr Fenech's daughter, that Mr Fenech's health had been declining over the months prior to his death. This decline was due to a fall which decreased his mobility, appetite and strength.

It was also made clear that Mr Fenech did not want to be resuscitated, and had previously mentioned to his daughter that he was 'ready to die'. Due to Mr Fenech's wishes and unsuitability for an MRI, Mr Fenech commenced palliative care at 11:21am on 10 November 2017. He was unable to survive his injuries and was found dead at 9pm on 11 November 2017.

The autopsy revealed a number of bruises and injuries believed to have occurred due to the fall of 9 November 2017. The autopsy determined that Mr Fenech had "developed terminal congestive heart failure due to an ischaemic cardiomyopathy as a consequence of coronary artery atherosclerosis", and the subluxation of the C1 and C2 vertebrae and atrial fibrillation could have been contributing factors in Mr Fenech's death.

Ms Marea Fenech raised a number of concerns relating to TriCare's treatment of her father. Primarily, she raised concerns relating to the failure to advise her of her father's deterioration in the days prior to his fall on 9 November 2017. Ms Fenech had also made 6 contacts and 4 complaints to the Aged Care Complaints Commissioner since January 2016. These complaints related to falls resulting in severe injuries, consultation and communication issues, clinical assessment and health and personal care.

Ms Fenech's key complaint was that TriCare failed to take preventative measures to stop Mr Fenech from falling, including consistent failure to ensure that his bedrails were in place.

TriCare implemented a number of measures to prevent similar falls. These measures included extra training for staff, system enhancements and the creation of a falls risk committee. TriCare also implemented bed and chair assist alarms which cannot be turned off for residents at a high risk of falling, auditing systems for those alarms and better management of reporting in relation to resident care plans and their reflection of falls risk strategies.


The Coroner found that the measures implemented by TriCare to prevent falls similar to that suffered by Mr Fenech, were sufficient to address the Coroner's concerns. Consequently, this investigation did not progress to an inquest and the Coroner closed the investigation

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