An 81-year-old woman with Lewy Body Dementia died from acute on chronic subdural haematoma following multiple falls in aged care. The nursing home had appropriately assessed her as high falls risk and implemented reasonable preventive strategies including bed alarms, low positioning, appropriate footwear, and mobility assistance. She suffered four documented falls over six months; the final unwitnessed fall on 18 June 2018 resulted in head injury. She deteriorated neurologically and was hospitalized 12 hours later with subdural haematoma. The coroner found that staff correctly implemented falls prevention measures and no further action could reasonably have prevented her death, given her progressive dementia and declining insight into safety risks.
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