Coroner's Finding: McKenzie, Alan John

92y · Male·heart failure secondary to ischaemic heart disease/arrythmia aggravated by a fall with cervical neck fractures

A 92-year-old man with dementia, Alzheimer's disease and COPD died following a fall from a defective princess chair in aged care. The chair's right armrest had a worn spring mechanism that failed to lock properly, allowing it to collapse when the resident leaned on it. Staff had reported maintenance concerns but no written request was submitted. The fall caused cervical spine fractures with epidural haematoma and spinal cord compression, ultimately precipitating fatal heart failure. The death was preventable: the chair should have been removed from service when faults were identified. Critical lessons include: formal equipment maintenance reporting systems must be implemented in aged care; staff concerns about equipment must be documented and escalated; regular equipment inspection protocols are essential; and equipment with identified faults must be immediately withdrawn from use until repairs are verified.