Inquest into the Death of Kathryn PAPANASTASIOU

74y · Female·Fractures of the legs, with terminal palliative care, in an elderly lady with multiple co-morbidities

Ms Papanastasiou, a 74-year-old aged care resident confined to a wheelchair, died from bilateral femoral fractures sustained when she fell from her wheelchair during sudden bus braking. The wheelchair was secured using only a shoulder strap, contrary to the applicable Australian Standard requiring a three-point restraint (pelvic lap-sash plus shoulder strap). The driver, under time pressure and distracted by a verbally abusive visitor, was unable to locate proper lap-sash straps due to poor equipment storage organisation, then made a clinical decision to proceed with inadequate restraint rather than remove the resident from the vehicle. The critical failures were: inadequate restraint system, failure to conduct proper risk assessment when standard restraint was unavailable, lack of mandatory supervision on the bus, and driver distraction. Key learning: transport safety requires strict adherence to standards, proper risk assessment, clear policies, and adequate staffing.