Coroner's Finding: Cash, Robert
Deceased
Robert Edward Cash
Demographics
89y, male
Date of death
2022-07-13
Finding date
2023-02-22
Cause of death
peri-prosthetic fracture of right femur
AI-generated summary
89-year-old man resident in aged care suffered an unwitnessed fall in his bathroom, sustaining a peri-prosthetic right distal femur fracture. He was assessed as high falls risk. Post-operatively his condition deteriorated with decreased consciousness; palliative care was adopted and he died 7 days later. The coroner noted that a sensor alarm was unavailable in his room at the time of the fall, though acknowledged this may not have prevented the fall. The coroner recommended installation of sensor alarms for high-risk residents. Key lesson: ensure falls prevention equipment is available and functional for residents identified as high falls risk in aged care settings.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Procedures
Contributing factors
- unwitnessed fall
- high falls risk assessment
- unavailable sensor alarm device
- advanced age
- cognitive decline
- general unsteadiness
Coroner's recommendations
- Regis Aged Care Pty Ltd should install sensor alarms in the rooms of residents where falls risk assessments warrant this measure
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