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. Report an inaccuracy.
Specialties
Error types
Clinical conditions
87y · Female·right thigh haematoma as a consequence of a periprosthetic fracture of the right…
An 87-year-old woman with multiple comorbidities (diabetes, atrial fibrillation, peripheral vascular disease) sustained a periprosthetic fracture requiring distal femur replacement. She deteriorated significantly during …
92y · Male·Consequences of accidental fall at RACF: post-operative delirium, left femoral i…
A 92-year-old man resident in an aged care facility sustained an unwitnessed fall resulting in left hip fracture, requiring surgical fixation. He developed post-operative delirium and died 8 days later. The coroner ident…
86y · Female·Hypostatic pneumonia due to the consequences of a right pubic rami fracture and …
An 86-year-old woman with advanced dementia and frailty suffered an unwitnessed fall at her aged care facility. Initial assessment failed to identify pubic rami and hip fractures. Post-fall documentation was insufficient…
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.