Finding into death of Angelo Raffaelle Palma

65y · Male·Intracranial haemorrhage following a fall

Angelo Palma, a 65-year-old man with intellectual disability living in supported accommodation, fell from bed early morning on 2 October 2015 after reporting feeling unwell and vomiting. He sustained a large left-sided acute-on-chronic subdural haemorrhage with midline shift. Despite rapid deterioration and neurosurgical consultation confirming poor prognosis, he died the following day. The coroner found no evidence that the fall was related to recent diabetes medication cessation, and found no deficiencies in falls risk assessment, general practice management, or hospital care. The death was not preventable given the acute nature of the intracranial injury.