The deceased, who had become increasing frail towards the end of 2009 following a back injury, fell at home on Christmas Eve 2009 and was taken to a respite facility later that day.

The next day, Christmas Day, the deceased had three falls at the facility. The Coroner found that the third fall caused a fracture of the deceased’s left femur. This fracture was not recognised at the time and the deceased was not admitted to hospital until 16 hours later. Surgical repair of the fracture was undertaken but the deceased died as a result of complications arising after the surgery.

The Coroner found that the deceased’s fall and consequent fracture set off a decline in her health, which ultimately led to her death. The Coroner found that the respite facility staff missed a number of opportunities to communicate important information to each other that might have allowed the fracture to be diagnosed earlier and for the deceased’s care to be properly managed. In particular, the nurses failed to:

  1. record entries in the progress notes that would have alerted the staff to the deceased’s injuries;
  2. take more extensive and regular observations;
  3. encourage a doctor to be called; or
  4. consider transferring the deceased to hospital after the fall.

The Coroner also found that handover procedures and communication between the facility’s staff were generally inadequate.]

Though the Coroner concluded that had staff followed the facility’s policy, the injury would have been diagnosed sooner, the facility was to be commended for taking steps to resolve some of the problems surrounding the deceased’s death. In particular, a new falls policy had been implemented under which all falls were to be referred to a GP and physiotherapist and staff members informed of a fall occurring in the previous shift.

The former practice of a primarily oral handover was changed to a written handover to avoid the potential for omission and miscommunication. The Coroner found that there was no need to make any recommendations in light of the action taken by the respite facility since the death.


Upon admission to an aged care facility, the deceased was diagnosed with a number of problems, including chronic cardiac failure and a recently amputated toe.

The falls procedure in place at the facility at the time provided for a resident’s falls risk to be assessed upon admission, followed by a referral to a registered nurse, physiotherapist, occupational therapist and GP to identify interventions to address risk factors.

Under this procedure, the deceased was assessed as a medium falls risk, and his care plan required that he be given assistance when toileting and be mobilised in a wheelchair with an assistant. The Coroner found that this procedure was appropriately implemented.

On the morning of 2 July 2010, the deceased had a fall. A GP examined the deceased that afternoon and found him confused as a result of either head trauma from the fall or an infected wound on his leg. Antibiotics were prescribed and the GP directed that the deceased be transferred to hospital if he did not improve. The deceased was monitored closely and a decision was made to transfer him to hospital later that evening. He died five days later of subdural haemorrhage sustained in the fall.

The Coroner concluded that the quality of care provided to the deceased at the aged care facility before and after the fall was reasonable and appropriate. As a result, no recommendations were made.

The Coroner commended action taken by the facility in 2012 to establish a focus group to review and implement best practices in relation to falls prevention and management.


The Coroner in Daniel pointed to an inadequacy of falls management procedures leading to delays in the identification of the deceased’s injuries. By the respite facility introducing a new handover system which automatically sent out alerts to staff at the beginning of a shift when a fall has occurred in the preceding shift, the Coroner’s concerns were addressed. The Coroner also found that the facility’s new falls policy, under which a nurse must report a fall to the resident’s doctor, was a positive step.

In Caporn, the Coroner approved of the facility’s falls prevention procedure, under which each resident was assessed for falls risk upon admission by a registered nurse, physiotherapist, occupational therapist and a GP to identify interventions to address risk factors. The Coroner looked favourably upon procedures under which falls risk are assessed early and tailored interventions are adopted to reduce the risk of falls.

Overall, aged care facilities should take comfort that coroners will look favourably on procedures that ensure that falls are reported in a timely manner and that ensure residents are promptly assessed and closely monitored following a fall.