Coroner's Finding: Gleeson, Bernice Valma
Deceased
Bernice Valma Gleeson
Demographics
84y, female
Date of death
2021-10-30
Finding date
2024-05-02
Cause of death
left subdural haematoma resulting from head injury due to fall from standing
AI-generated summary
An 84-year-old woman suffered a fatal head injury after slipping on steps at a café in Stanley, Tasmania on 20 October 2021, resulting in a left subdural haematoma. She was appropriately transported to neurosurgical facilities and underwent emergency evacuation of the haematoma, but died 8 days later. The coroner found her prior fall in August 2021 was thoroughly assessed with appropriate clinical follow-up, and did not warrant additional preventive interventions. The delay in surgery (initially scheduled for 25 October, advanced to 22 October due to deterioration) was justified given the need to manage her aspirin use before surgery and the severity of her injury. Post-operative seizures and infarcts were recognised complications. The case highlights appropriate trauma management and neurosurgical care, with the only recommendation concerning improved hazard signage at the café premises.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Drugs involved
Clinical conditions
Contributing factors
- slip/trip on steps in café
- age and reduced physiological reserve
- aspirin use (anticoagulant effect)
- inadequate hazard warning signage
Coroner's recommendations
- Erect much larger, bold and distinctive warning signs in both directions at the steps in Touchwood Cottages Gallery and Café to improve visibility and distinguish from background surfaces
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