In December 2015, an inquest1 was held into the death of an aged care resident, Ms Ena Vickers, following a fall.


Mrs Vickers, who suffered from dementia, Parkinson’s disease and declining cognitive function, fell over in her room. The fall was not witnessed, however, a personal care attendant (PCA) assisted Mrs Vickers back to her bed.

No nurses were on duty in Mrs Vickers’ area of the facility at the time. Accordingly, the PCA brought Mrs Vickers’ fall to the attention of an enrolled nurse in a different area. Mrs Vickers was then assessed by two enrolled nurses, with one telephoning her local GP for advice. Based on the nurse’s discussion with the GP, a decision was made to not convey Mrs Vickers to hospital, but rather monitor her condition at the nursing home.

The nurse’s conversation with the GP was not documented until the following day and the name of the GP was not included in the patient’s notes.

Monitoring of Mrs Vickers was only documented for about 90 minutes immediately after the fall although it was suggested at the inquest that further undocumented monitoring occurred. At 4pm, Mrs Vickers’ family visited and found her to be in distress. An ambulance was called and Mrs Vickers was conveyed to hospital where tests revealed that she had suffered a fracture to C7, a fractured neck of femur, and a sub-dural haematoma and subarachnoid haemorrhage. Following further investigations and consultation with Mrs Vickers’ family, she was palliated, passing away five days later.


The Coroner found that the initial assessment of Mrs Vickers was deficient and that advice from a registered nurse or a doctor ought to have been sought. Despite this, the Coroner noted that earlier medical attention may not have changed the outcome. In other words, he was not comfortably satisfied that admission to hospital some 4-5 hours earlier would have prevented Mrs Vickers’ death.

The Coroner criticised the nursing home’s lack of formal postincident review, noting that mere discussions with staff involved “were an inadequate response to the circumstances leading to [Mrs Vickers’ untimely] death.” The Coroner suggested that a proper review would have identified inadequacies in the medical records.


The inquest highlights the importance of aged care facilities having a formal, robust internal review process that can be implemented following a serious event. The Coroner noted that had an adequate internal review taken place, the recollections of the staff involved would have been sought and recorded while still fresh in their minds, and examination of the facility’s compliance with its practices and protocols analysed. Review processes of this nature are increasinlgy important in the Coronial jurisdiction, as it may be a number of years before an inquest is held, witnesses called to give evidence and learnings established. Should a facility anticipate coronial or civil proceedings as a result of a death, strong consideration should be given to seeking expert legal advice.