Coroner's Finding: FROST Gary Desmond

57y · Male·Right acute subdural haematoma following a fall

Gary Desmond Frost, a 57-year-old man with intellectual disability, dementia, and schizophrenia, died from a right acute subdural haematoma following a fall while in supported residential care. He experienced multiple falls over several weeks with head trauma. On 11 February 2019, after falling backwards and striking his head despite wearing a helmet, he developed a large acute subdural haematoma with severe brain injury and uncal herniation. Neurosurgical consultation concluded surgery would not improve outcome. The coroner found his care at both the residential facility and hospital was appropriate and the tragic outcome was difficult to prevent. No systemic failures or negligence were identified. The patient's complex behavioural needs and intellectual disability made management challenging but appropriate clinical decisions were made throughout his treatment course.