Coroner's Finding: Bradley, Steven Basil
Deceased
Steven Basil Bradley
Demographics
65y, male
Date of death
2024-03-09
Finding date
2026-02-24
Cause of death
Acute on chronic subdural haematoma caused by accidental falls
AI-generated summary
Steven Basil Bradley, 65, died from acute on chronic subdural haematoma following an unwitnessed fall in hospital. He had metastatic prostate cancer, ischaemic heart disease, and diabetes. On admission for chest sepsis, a CT brain identified a pre-existing subacute subdural haematoma from a prior fall. Despite documented fall history, no falls assessment, mobility evaluation, or comprehensive care plan was completed during his two-week admission. No hourly overnight rounding occurred. The 6 March fall extended the pre-existing haematoma; he died 3 days later. While causation is uncertain given his significant comorbidities, the coroner found falls prevention measures were inadequate. The hospital has since implemented intentional rounding, improved falls risk recognition, and comprehensive care planning.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Clinical conditions
Procedures
Contributing factors
- Lack of falls assessment despite documented fall history
- No mobility or functional assessment on admission or during stay
- Comprehensive care plan not completed
- No hourly overnight rounding
- Metastatic prostatic adenocarcinoma
- Atypical pneumonia
- Prior subdural haematoma from earlier fall
Coroner's recommendations
- The Royal Hobart Hospital should review the operation and efficacy of its falls assessment and prevention strategies at appropriate intervals
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 —