ANDERSON Norman
Deceased
Norman Anderson
Demographics
83y, male
Date of death
2000-11-14
Finding date
2002-05-09
Cause of death
Traumatic asphyxia in a man with coronary artery atherosclerosis
AI-generated summary
Norman Anderson, 83, died from traumatic asphyxia when he became entrapped face-down in the mesh webbing of a Siltex 'Disappearing Cotside' bed rail at Toorak House aged care facility on 14 November 2000. The coroner found the facility should have recognized the hazard and removed these cotsides after a similar death of another resident (Richard Grace) just 10 weeks earlier on 23 August 2000. Both residents died from entrapment in the same product. The coroner found Blue Cross management failed to identify the danger due to inadequate incident reporting systems and failure to adequately investigate Grace's death. While monitoring of Anderson was appropriate, the continued use of a demonstrably hazardous product after warning signs constituted a system failure. The coroner recommended urgent withdrawal of Disappearing Cotsides from use and comprehensive review of incident reporting systems.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Contributing factors
- Entrapment in mesh webbing of Siltex Disappearing Cotside bed rail
- Inadequate incident reporting system at facility
- Failure to recognize product hazard following similar death of Mr. Richard Grace 10 weeks prior
- Inability to self-extricate due to advanced age, Alzheimer's disease, Parkinson's disease and dementia
- Lack of comprehensive investigation and debriefing of staff regarding preceding death at same facility
Coroner's recommendations
- In light of deaths of Mr. Richard Grace and Mr. Norman Anderson, together with previous recommendations made by Coroner Chivell in South Australia regarding Hayden McFadyen (1998), urgent consideration be given to withdrawal of Disappearing Cotsides from use
- This finding and recommendations be disseminated to: Victorian Department of Human Services, Commonwealth Department of Health and Family Services, and Aged Care Standards Agency
- If Disappearing Cotsides are not withdrawn, the product be listed under the Therapeutic Goods Act 1989 (Commonwealth) so that an evaluation of safety can be undertaken
- Blue Cross Community Care Services Group comprehensively review their incident reporting systems
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 —