Deceased
Garry Serve
Demographics
82y, male
Coroner
Deputy State Coroner Paresa Spanos
Date of death
2015-11-20
Finding date
2017-11-15
Cause of death
Trauma related intracerebral haemorrhage
AI-generated summary
An 82-year-old man with dementia, cerebellar ataxia, and mobility limitations fell from his wheelchair down three concrete steps (480cm drop) while attending a hearing aid appointment at an off-site clinic. He sustained fatal traumatic intracerebral haemorrhage. Key clinical lessons: staff escorting residents off-site lacked specific training on wheelchair safety and off-site protocols; the wheelchair brakes were not engaged before the resident was left unattended; no documentation was taken regarding his medical conditions or mobility needs; and there was no assessment of environmental safety at the destination. The coroner found no definitive mechanism for the fall but noted the resident's cerebellar ataxia would have prevented him from breaking a fall reflexively. Bupa subsequently implemented improved training, checklists, equipment audits, and mandatory seatbelt use for wheelchairs.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
39y · Male·Mixed drug toxicity (heroin, venlafaxine, alprazolam, pregabalin) with contribut…
Kevin Thomas Maloney, a 39-year-old man with complex mental health conditions and substance use disorder, died from mixed drug toxicity (heroin, venlafaxine, alprazolam, pregabalin) while residing in a supported resident…
89y · Female·Acute upper airway obstruction by food bolus
An 89-year-old woman with dementia died from acute upper airway obstruction by food bolus while being fed lunch at an aged care facility. CCTV footage revealed significant discrepancies between reported actions and actua…
80y · Female·multiple injuries in the setting of a fall
Catherine Mary Reid, aged 80, died from multiple fractures sustained in a fall during a mechanical hoist transfer at a disability care facility. While being transferred from wheelchair to bed using an overhead ceiling ho…
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