Coroner's Finding: Bird, Allan Roy

92y · Male·Consequences of accidental fall at RACF: post-operative delirium, left femoral intramedullary nail insertion, and left neck of femur intertrochanteric fracture; contributed to by age-related frailty, coronary artery disease, hypothyroidism, and atrial fibrillation

A 92-year-old man resident in an aged care facility sustained an unwitnessed fall resulting in left hip fracture, requiring surgical fixation. He developed post-operative delirium and died 8 days later. The coroner identified missed opportunities in falls risk assessment and prevention. Mr Bird was assessed as low falls risk despite being 92 years old, taking three medications including a benzodiazepine that increase fall risk, having documented impulsivity regarding mobility, and lacking a comprehensive care plan following transition to permanent residency. No formalised falls prevention strategies were clearly documented. Enhanced supervision, bed sensors, and hip protectors should have been considered. The coroner acknowledged the patient's tendency to mobilise without assistance may have led to a fall regardless, but proper risk recognition and mitigation could have prevented or reduced injury severity.