Coronial
TASaged care

Coroner's Finding: Kerr,Anthony Neville

Deceased

Anthony Neville Kerr

Demographics

81y, male

Date of death

2021-06-10

Finding date

2022-11-08

Cause of death

pneumonia due to traumatic internal bleeding of the chest wall sustained in fall on 6 June 2021

AI-generated summary

An 81-year-old man with Parkinson's disease, dementia, and multiple comorbidities residing in aged care suffered an unwitnessed fall on 6 June 2021, sustaining a right-sided chest wall haematoma. Staff found him at 7:40am with low blood pressure and bruising; his doctor was contacted at 11:00am and an ambulance called at 3:00pm when chest swelling developed. He was treated with medication and blood transfusion but developed pneumonia and deteriorated rapidly, dying on 10 June. The coroner found no significant failures by the nursing home. A motion sensor alarm had been removed because the resident tampered with it; the coroner noted that alternative alarm types (such as bed alarms) might have been trialled. The delay in ambulance transfer was unlikely to have changed the outcome.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

geriatric medicineemergency medicine

Error types

delaysystem

Clinical conditions

traumatic chest wall haematomapneumoniaParkinson's diseasedementiaheart diseaserespiratory diseasefalls risk

Procedures

blood transfusion

Contributing factors

  • unwitnessed fall in high-risk resident
  • right-sided chest wall haematoma from fall trauma
  • delayed recognition of deterioration
  • development of secondary chest infection
  • removal of motion sensor alarm due to resident tampering
Full text

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. Some material may have been redacted or restricted by court order or privacy requirements. 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 — report an inaccuracy here.