On 17 May 2019 the Coroner's Court of Victoria released findings into the death of Mabel Grace Ellen Pritchard from hospital acquired pneumonia in the setting of recent fractures secondary to falls.

The Coroner made a number of comments on the adequacy of Mrs Pritchard's care. Accordingly, the Coroner considered it appropriate to provide a copy of the Findings to the Commissioners of the Royal Commission into Aged Care Quality and Safety.

Background Facts

Mrs Pritchard resided in an aged care facility called Elizabeth Gardens and was 90 years old at the time of her death. She had a significant medical history including intrathoracic aneurysm, congestive cardiac failure, acoustic neuroma, hypertension and forgetfulness. She was unable to walk independently and had been categorised by her aged care facility as a high falls risk.

On 17 January 2018, Mrs Pritchard fell onto her posterior when attempting to sit on her bed. Emergency services were contacted and she was transported to Box Hill Hospital. She was diagnosed with a broken hip and, on 21 January 2018, she underwent surgery to have a pin inserted into her hip. During her stay at hospital, she contracted pneumonia and a urinary tract infection.

Mrs Pritchard was transferred to the Peter James Centre for rehabilitation where she had an unwitnessed fall. On 3 February 2018, she had a second unwitnessed fall from which she suffered fractured humerus and neck of femur. The staff at the rehabilitation centre were advised to treat her conservatively.

On 6 February 2018, Mrs Pritchard was transferred back to the Box Hill Hospital for medical management and orthopaedic review. She was treated intravenously for pneumonia. She became increasingly unwell and agitated. On 9 February 2018, she was found to have deep vein thrombosis.

On 10 February 2018, the staff at Box Hill hospital and Mrs Pritchard's family made a decision to cease active treatment and continue with comfort management. Later than day, she was pronounced deceased.


A forensic pathologist made findings that were consistent with Mrs Pritchard's known, recent medical history. CT scanning also detected calcific coronary artery disease, cardiomegaly and bilateral pleural effusions. The forensic pathologist considered the cause of Mrs Pritchard's death to be hospital acquired pneumonia in the setting of recent fractures of neck of humerus and neck of femur (operated) secondary to falls.

Victoria Police had attended Box Hill Hospital, upon a notification of Mrs Pritchard's death being a reportable death pursuant to the Coroners Act 2008 (Vic). During their investigations, the police learned that Mrs Pritchard's children had some concerns about her care and treatment. Mrs Pritchard's daughter delivered a statement that, amongst other things, referred to some concerns in relation to:

  1. the staffing ratios at the Peter James Centre;
  2. the capacity of the Peter James Centre to care for and treat their mother's condition.

She also stated that she felt the Box Hill Hospital's care had been exemplary and noted that all care providers had acted with the best intentions.

The Peter James Centre provided a statement in response. It stated that the facility complied with the staffing ratios required by legislation. While the doctor and allied health staffing to patient ratios are not set by legislation, the ratios were in keeping with the current practice in Victoria. The statement also commented on the demands made of all practitioners in light of the multiple pressing needs of patients, particularly in the context of aged care. The need to urgently respond to multiple patients' needs is compounded by patients who mobilise in an unsafe manner, such as those suffering dementia.

In relation to the family's concerns that Mrs Pritchard has not been transferred to hospital immediately after her second fall, it was suggested that she did not, at that time, require the high-technology services provided at Box Hill Hospital.

Findings and Comments

The Coroner adopted the cause of death formulated by the forensic pathologist, finding the care and treatment provided to Mrs Pritchard appeared to be reasonable and appropriate in the circumstances.

The Coroner commented that despite staff ratios meeting the legislative requirements and/ or being consistent with current practice, there 'may still be instances where staff members need to balance the urgent need of multiple patients'. The issue appears to be of particular concern in aged patients who have experienced cognitive and physical decline but are still mobilising.

The Coroner stated that a copy of the Findings would be provided to the Commissioners of the Royal Commission into Aged Care Quality and Safety in the hope that it would provide further insight and assist their activities.