Finding into death of Garry Serve
Deceased
Garry Serve
Demographics
82y, male
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.
Error types
Drugs involved
Contributing factors
- Wheelchair brakes not engaged before resident left unattended
- Lack of training for staff on wheelchair safety and management
- Lack of training for staff on off-site escort procedures
- No medical documentation taken off-site
- No environmental safety assessment at destination
- Resident left on landing near stairs while staff arranged taxi
- Resident's cerebellar ataxia prevented protective reflexes
- Resident's inability to self-mobilise in wheelchair
Coroner's recommendations
- Bupa revised policies to enhance training for staff who escort residents on outings
- Bupa changed resident suitability for outings checklist
- Bupa ensured mobility aids are in good repair by monthly audit
- Bupa mandated use of seatbelts in wheelchairs
Full text
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