Coroner's Finding: Bradburn, Lester Basil
Deceased
Lester Basil Bradburn
Demographics
73y, male
Date of death
2023-11-09
Finding date
2024-11-18
Cause of death
Traumatic head, facial and chest injuries caused by fall down stairs at residential aged care facility
AI-generated summary
A 73-year-old man with Parkinson's disease and recent falls died from traumatic injuries after falling down six stairs while exiting a residential aged care facility at 5:00 AM. He had been admitted only 10 days prior and had already experienced documented wandering and two falls. The coroner identified multiple preventable safety gaps: the front door was unlocked during early morning hours when it should have been secured until 7:00 AM; a wandering alarm was not implemented despite documented wandering behaviour and disorientation; and floor sensors failed to detect his departure because he may have stepped around the mat. Clinical lessons include the need for prompt risk assessment upon admission to aged care, timely implementation of appropriate safety measures for residents with fall and wandering risks, robust physical security protocols, and contemporaneous documentation of resident checks, particularly during night shifts.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Contributing factors
- Unlocked front door during early morning hours
- Failure to implement wandering alarm despite documented wandering behaviour
- Floor sensor mat did not activate due to resident stepping around it
- Early admission stage with care plan still being developed
- Lack of orientation to time and documented early rising behaviour
- Inadequate initial risk assessment
- Lack of contemporaneous documentation of staff checks
Coroner's recommendations
- Respect Aged Care Derwent Views should review its policies and processes surrounding the safety of residents, particularly those prone to wandering and falls
- Review adequacy and timeliness of risk assessments upon admission
- Review access to and from the facility
- Review the adequacy of existing sensors to detect movement
- Review the checking of residents overnight
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