Finding into death of Leslie Roberts

76y · Male·Hypothermia and multiorgan failure complicating compound left tibia and fibula fractures sustained in a fall

Leslie Roberts, a 76-year-old man with intellectual disability under DHHS care, died from hypothermia and multiorgan failure following a compound fracture of the left tibia and fibula sustained in a fall at home. He was found unresponsive after welfare concerns were raised. The coroner identified that adequate welfare checks were not conducted when multiple contact attempts failed on 3 July 2018, despite Mr Roberts being known to always be home at appointment times. While the coroner deemed the death preventable, they could not establish causation with requisite certainty. Key clinical lesson: when vulnerable clients with established routines fail to respond to contact at expected times, timely welfare checks involving emergency services should be triggered rather than dismissed based on assumptions about their movements.