Coroner's Finding: Whelan, Brian John

84y · Male·head and pelvic injuries with contributing ischaemic and valvular heart disease (operated)

An 84-year-old man under guardianship with dementia, cardiac disease, and on anticoagulation suffered an unwitnessed fall at an aged care facility and sustained head and pelvic injuries. Following the fall, a registered nurse appropriately called an ambulance. However, a significant delay occurred—SAAS took approximately 6.5 hours to arrive due to inability to contact the facility because night staff had not switched the main phone lines to the residential floor. Despite this delay, the coroner found no impact on outcome, as the patient had an advance care plan declining life-prolonging treatment and was receiving appropriate nursing care in the interim. Care at both the aged care facility and hospital was deemed appropriate. The facility has since implemented automated phone switching to prevent recurrence.