Coroner's Finding: Whelan, Brian John
Deceased
Brian John Whelan
Demographics
84y, male
Date of death
2021-02-17
Finding date
2024-06-19
Cause of death
head and pelvic injuries with contributing ischaemic and valvular heart disease (operated)
AI-generated summary
An 84-year-old man under guardianship with dementia, cardiac disease, and on anticoagulation suffered an unwitnessed fall at an aged care facility and sustained head and pelvic injuries. Following the fall, a registered nurse appropriately called an ambulance. However, a significant delay occurred—SAAS took approximately 6.5 hours to arrive due to inability to contact the facility because night staff had not switched the main phone lines to the residential floor. Despite this delay, the coroner found no impact on outcome, as the patient had an advance care plan declining life-prolonging treatment and was receiving appropriate nursing care in the interim. Care at both the aged care facility and hospital was deemed appropriate. The facility has since implemented automated phone switching to prevent recurrence.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- unwitnessed fall
- delayed ambulance response due to phone system failure
- anticoagulation therapy
- advanced age
- comorbid cardiac disease and dementia
Full text
Related cases
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —