Coroner's Finding: Slatter, Ronald Reginald
Deceased
Ronald Reginald Slatter
Demographics
93y, male
Date of death
2022-07-22
Finding date
2023-08-02
Cause of death
Alzheimer's dementia (as recorded on MCCD); however, the death resulted from a fall causing fracture of neck of right femur with subsequent complications
AI-generated summary
Ronald Reginald Slatter, aged 93, died at Mersey Community Hospital on 22 July 2022, three weeks after sustaining a fractured neck of right femur from a fall on 1 July 2022. While the coroner found no issues with his clinical care, a critical administrative failure occurred: the Medical Certificate of Cause of Death listed only Alzheimer's dementia and completely omitted reference to the fall and fracture that directly contributed to his death. The death was not reported to the coroner as legally required, discovered only during internal review in late September 2022. The coroner emphasised that all hospital medical staff must familiarise themselves with Coroners Act 1995 reporting requirements for deaths resulting from accidents or injuries, regardless of patient age or comorbidities.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Procedures
Contributing factors
- fall from chair on 1 July 2022
- fracture of neck of right femur
- advanced age (93 years)
- Alzheimer's dementia
- failure to report death as required by Coroners Act 1995
- incomplete Medical Certificate of Cause of Death omitting reference to fall and fracture
Coroner's recommendations
- All members of the medical staff of all hospitals should familiarise themselves with the requirements under the Coroners Act 1995, particularly regarding reportable deaths that appear to have resulted directly or indirectly from an accident or injury
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 —