Coroner's Finding: Gray, Laurence Keith

96y · Male·Traumatic closed head injuries sustained in a fall

A 96-year-old man with cognitive impairment and previous traumatic brain injury from a 2021 fall was admitted to residential aged care on 16 February 2022. He had a minor slip from his chair on admission day without injury. On 19 February, he was found on the bathroom floor and sustained traumatic closed head injuries (skull fracture, frontal lobe contusion, subarachnoid bleed) from which he died two days later. A coronial nursing consultant found no clinical red flags in his care. Falls risk assessment was appropriately completed on admission and he was assessed as high-risk. While the nursing home's documentation of falls prevention strategies was incomplete, the consultant considered documented strategies sound. No adverse findings were made against care providers. The coroner noted only a process issue regarding the timely provision of documentation to the coroner's office.