Finding into death of Garry Serve

82y · Male·Trauma related intracerebral haemorrhage

An 82-year-old man with dementia, cerebellar ataxia, and mobility limitations fell from his wheelchair down three concrete steps (480cm drop) while attending a hearing aid appointment at an off-site clinic. He sustained fatal traumatic intracerebral haemorrhage. Key clinical lessons: staff escorting residents off-site lacked specific training on wheelchair safety and off-site protocols; the wheelchair brakes were not engaged before the resident was left unattended; no documentation was taken regarding his medical conditions or mobility needs; and there was no assessment of environmental safety at the destination. The coroner found no definitive mechanism for the fall but noted the resident's cerebellar ataxia would have prevented him from breaking a fall reflexively. Bupa subsequently implemented improved training, checklists, equipment audits, and mandatory seatbelt use for wheelchairs.