In August 2016, the Commonwealth Department of Health produced an industry alert addressing the need for CT head scans to be performed following a fall. In this article, we discuss the Coronial inquest1 from which the alert arose.


Mrs Marie Ford, aged 84 years, resided at the Christies Beach Residential Care Service in South Australia. Mrs Ford suffered from dementia, general frailty, immobility, blindness and was on Warfarin anti-coagulant treatment following a deep vein thrombosis.

On around 2 April 2011, Mrs Ford suffered an unwitnessed fall whilst seated in a princess chair in a common area of the facility. Facility staff quickly attended to Mrs Ford. She was assessed and observed over the subsequent hours with nothing of significance noted.

Mrs Ford’s condition subsequently deteriorated and she was transferred to the Flinders Medical Centre where she passed away as a result of acute left subdural haemorrhage.


The Coroner was generally not critical of the care and treatment of Mrs Ford prior to or after the fall but noted that overnight, her neurological observations were inadequate. This arose as a result of an agency nurse independently determining that as Mrs Ford suffered from dementia, if woken regularly for observation, she would find it difficult to go back to sleep. The Coroner was critical of the agency nurse and said that the decision “smacks of staff convenience more than concern for the patient and reflected a compromised standard of care”.

The Coroner also considered what should be the appropriate response to a fall with a minor head injury in a frail nursing home resident, and whether there should be a difference in response when the resident is being treated with anti-coagulation therapy.

An expert who reviewed Mrs Ford’s death for the Coroner questioned whether CT scanning in patients with a minor head injury should be routine. The expert also considered whether physical restraint of residents with a high risk of falling is an effective preventative strategy. On this latter point, the evidence at the inquest was that physical restraint in an aged care setting is not effective and that, although the frequency of falls may be lowered as a result of such a strategy, statistics demonstrated that there is an increased likelihood of injurious falls or mortality. 

In relation to the question regarding the need for CT scanning, the Coroner concluded that:

• at the time of the incident, it was not routine practice for nursing homes in Adelaide to refer residents for a CT scan;

• the rates of intra-cerebral bleeding are much higher for those patients who are on anti-coagulants, as compared to those who are not;

• residents with pre-existing cognitive impairment suffer from cerebral shrinkage, meaning that it is often difficult to detect intra-cranial bleeding until it becomes too late.

The Coroner agreed with the expert’s opinion that aged care facilities should consider implementing a policy requiring residents, who suffer a fall resulting in minor head injury, to be referred to hospital for assessment and if the patient is on anti-coagulation therapy, consideration should also be given to the need to conduct a CT scan.

The Coroner referred the matter to the South Australian Minister for Health, the South Australian Minister for Aging and the Commonwealth Minister for Health & Aged Care to consider producing a protocol along these lines.

In August of this year, the Commonwealth Department of Health issued an industry alert highlighting the Coroner’s findings and recommending that aged care facilities make all key personnel aware of the information in the finding and the industry alert. A link to the industry alert can be found at https://agedcare.


Aged Care facilities and hospitals should conduct education sessions (and record staff attendance) to ensure that all relevant personnel are made aware of the key points arising from this inquest and the Coroner’s findings. Policies and protocols should also be updated to take account of the recommended changes in practice.

Although not a legislated requirement, in our view there would be a strong argument that any organisation which does not adapt to the industry alert will be open to criticism and possible compensation claims should a resident suffer injury or death as a result of a failure to refer to hospital and further investigation.