Deceased
Anthony Charles Debono
Demographics
97y, male
Coroner
Coroner Rosemary Carlin
Date of death
2017-01-31
Finding date
2019-03-19
Cause of death
Complications of a fractured left neck of femur (operated), sustained in a fall
AI-generated summary
A 97-year-old man with vascular dementia, visual impairment, gait instability and multiple falls risk factors fell during a supervised outing from his aged care facility and sustained a fractured neck of femur. Despite being classified as an extreme falls risk requiring constant supervision and not to be left unattended, he was taken on an outing with inadequate risk assessment, planning, and staffing. The fall occurred when exiting the bus at a restaurant. He underwent surgery but developed post-operative complications including respiratory deterioration, leading to palliation and death. The coroner found the outing care was inappropriate due to inadequate communication of falls risk, inadequate wheelchair use planning, insufficient staffing for resident dependency, and unsafe venue access. A wheelchair may have prevented the fall.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Clinical conditions
Procedures
87y · Female·Complications of head injuries and left proximal femur fracture sustained in a f…
An 87-year-old woman with Parkinson's disease sustained an unwitnessed fall at a residential aged care facility, resulting in head injuries and a hip fracture. Critical clinical lessons emerged: (1) neurological observat…
90y · Female·Choking
A 90-year-old woman with dysphagia died from choking after consuming thin fluid (coffee) against medical recommendation. She had been reviewed by a speech pathologist on 15 November 2024 who recommended thick fluids only…
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…
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.