Coroner's Finding: Emery, Judith Anne
Deceased
Judith Anne Emery
Demographics
74y, female
Date of death
2016-09-24 to 2016-09-26
Finding date
2020-04-08
Cause of death
Chest and abdominal injuries from fall from cliff; possible terminal drowning
AI-generated summary
Judith Anne Emery, aged 74, died from chest and abdominal injuries sustained in a fall from a cliff near her retirement village, with possible terminal drowning. She was last seen on 24 September 2016 delivering a meal to her room, and her body was found on the rocky foreshore below cliffs on 26 September. The coroner could not definitively determine whether her death was accidental, suicidal, or homicidal. Key clinical lessons include the importance of comprehensive baseline assessment of residents in aged care facilities, documentation of any changes in mental state or behaviour, and timely escalation of welfare concerns. Staff observations that Ms Emery was acting strangely and unusually polite shortly before her disappearance were not formally documented or investigated. The investigation itself was significantly hampered by delayed collection of affidavits from staff, incomplete documentation of her communications and movements, and poor coordination of investigative efforts.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Fall from unfenced cliff approximately 6 metres high
- Possible walking in dark or agitated state
- Inadequate assessment and documentation of recent behavioural changes
- Limited staff knowledge of resident's movements and habits
- No safety barriers or appropriate fencing at cliff edge
- Delayed identification of missing person
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