Inquest into the death of Leslie ARMSTRONG

84y · Male·Multiple blunt force injuries sustained from fall from balcony

An 84-year-old man died from blunt force injuries sustained when he fell from a second-floor balcony at an aged care facility. Investigation revealed the balcony railings had failed due to wood rot and structural deterioration, despite the facility being aware since 1999 that repairs were needed. A maintenance worker had raised urgent safety concerns in August 2009, but management failed to act despite planned replacement works. The facility was accredited as safe by the Quality Agency just weeks before the death. Key lessons: aged care facilities require robust maintenance systems for structural safety; management must respond promptly to urgent safety concerns; accreditation processes must verify structural integrity of balustrades; and systems must prevent safety issues from being deprioritized in favor of other concerns.