Finding into death of Nikolaos Margelis

82y · Male·Traumatic head injury due to head striking the floor

An 82-year-old man with Alzheimer's dementia residing in a secure aged care facility died from traumatic head injury sustained when he was pushed by another resident during an interaction in a hallway. The deceased had a history of intrusive behaviour and had recently had his psychotropic medications reduced then re-increased. He fell backwards striking his head on the floor, sustaining extensive intracranial injuries including subdural haemorrhage and transtentorial herniation. He was transported to hospital but given the severity of injuries and comorbidities, a decision was made against surgical intervention and he died two days post-injury. The coroner found the death was not preventable as the push was unpredictable. However, the case highlights challenges in managing resident-to-resident aggression in aged care facilities caring for cognitively impaired individuals with behavioural disturbances.