Finding into death of Cecil John Dunne

86y · Male·head injury (acute intracerebral haemorrhage and subarachnoid haemorrhage)

An 86-year-old man with recurrent falls history was admitted to hospital after a fall at home. He was initially assessed as low falls risk (11/20 on FRAT) but then reassessed as medium risk. Despite falls interventions including observation, he had an unwitnessed fall outside his room at 2:35am on day 2, resulting in acute intracerebral and subarachnoid haemorrhage. He deteriorated and died. The coroner identified that the initial FRAT assessment may have been inaccurate due to insufficient information about his falls history from family members. Key clinical lessons: obtain collateral history from family about falls frequency and pattern, recognise that recurrent falls warrant higher risk stratification, ensure early senior review after in-hospital falls in elderly patients on anticoagulation, and implement appropriate supervision protocols for high-risk patients.