Coronial

31 results for wandering behaviour

NSWhospital2022-03-11

Inquest into the death of Kelvin Forrest

53y · Male·multiple injuries sustained in a fall from the first floor

…cal patient awaiting NDIS funding approval for supported independent living. Despite documented frequent wandering behaviour, including an incident where he was found on the road outside the hospital, supervision was in…

general medicinegeriatric medicinediagnosticcommunication
NSWaged care2023-07-14

Inquest into the death of William John Torrens

73y · Male·unknown

…sion, the GP did not recognise cognitive impairment on brief assessment, and there was no recognition of wandering behaviour as a serious dementia-related risk requiring secure placement or close monitoring. The nursing…

geriatric medicinegeneral practicediagnosticcommunicationsertraline
TASaged care2024-11-18

Coroner's Finding: Bradburn, Lester Basil

73y · Male·Traumatic head, facial and chest injuries caused by fall down stairs at resident…

…care facility at 5:00 AM. He had been admitted only 10 days prior and had already experienced documented wandering and two falls. The coroner identified multiple preventable safety gaps: the front door was unlocked duri…

geriatric medicineneurologysystemcommunication
NTcommunity2024

Inquest into the death of Road Death 4 of 2024

34y · Male·Multiple blunt force injuries from motor vehicle crash (pedestrian struck)

…of actively implementing care plans (particularly hi-vis requirements for vulnerable patients at risk of wandering), the need for active supervision protocols during high-risk periods, and ensuring environmental factors…

psychiatrysystemcommunication
NSW2023-02-09

Inquest into the disappearance and suspected death of Alexander Stetz

72y · Male·Unable to be determined

…ing terrain. While supervision was attentive given circumstances, the remote location and rapid onset of wandering behaviour highlights risks of caring for cognitively impaired elderly patients in isolated settings with…

geriatric medicineemergency medicine
QLDcommunity2017-11-09

Vance, Jason John

42y · Male·Undetermined

… was never found. The coroner concluded Jason died from misadventure rather than foul play, likely after wandering into bushland under the influence of methamphetamine—consistent with his known behaviour pattern. The in…

delaycommunicationmethamphetamine
VICaged care2011-10-21

Finding into death of Claus J Neff

76y · Male·MULTIPLE INJURIES IN A TRAIN INCIDENT

…the front door and was struck by a train, sustaining fatal injuries. The RN admitting him documented his wandering risk only in a falls risk assessment rather than the care plan, and failed to implement safety measures …

geriatric medicinepsychiatrycommunicationsystem
NSWcommunity2024-10-22

Inquest into the death of Cecilia Devine

41y · Female·Cause of death could not be established due to advanced decomposition

…idence in missing persons cases (lost to over-recording); consideration of how mental health crises with wandering behavior, combined with unfamiliar terrain and failing light, create fatal risks; and the importance of …

forensic medicinepsychiatrysystemdelaycannabis
VICaged care2019-05-30

Finding into death of S B

87y · Male·Complications of head injuries in setting of dementia

…g home resident. The deceased had a documented tendency to wander and enter other residents' rooms; this behaviour was a known risk but managed only by redirection. The perpetrator had a history of aggression toward sta…

geriatric medicineforensic medicinesystemcommunicationclopidogrel
VICcommunityPodcast2024-03-15

Finding into death of Colleen Mary South

58y · Female·Unascertained

…ersons; (3) recognition that mental health crises combined with life stressors can precipitate high-risk wandering behaviour. The coroner identified missed opportunities: Charlton Police Station being unmanned delayed i…

psychiatryemergency medicinesystemdelayaripiprazole
VICaged care

Finding into death of EMILIO VILLANUEVA

87y · Male·acute renal failure and two major haemorrhagic strokes

…ilure to implement recommended fall prevention measures following an unwitnessed fall, failure to manage wandering behaviours despite high-risk assessment, inadequate assessment of the serious burn injury and potential …

geriatric medicinegeneral medicinecommunicationsystemmetformin
VICaged care2020-07-22

Finding into death of Dorothy Boyle

92y · Female·Complications of a fractured left femur (operated), sustained in a fall

…t femoral fracture sustained in a fall at an aged care facility. She fell while attempting to push out a wandering dementia-affected resident who had entered her room. Although Mrs Boyle had requested her door be kept l…

geriatric medicineemergency medicinesystemprocedural
NSWcommunity2026-04-10

Inquest into the suspected death of Youliang Lin

84y · Male·The available evidence does not allow for any finding to be made as to the cause…

An 84-year-old man with Alzheimer's dementia and a history of wandering left his home on 15 September 2017 and was never found alive. The coroner determined he is deceased, lik…

geriatric medicinegeneral practicedelaycommunication
QLDaged care2019-02-12

Quayle, Betty Christine - Non-inquest findings

89y · Female·Blunt force head injury on a background of ischaemic and valvular heart disease

…ia in an aged care facility. The resident had a documented history of physical aggression, verbal abuse, wandering, and absconding over 19 months. He was transferred from a secure to non-secure unit six days after strik…

geriatric medicinegeneral practicesystemcommunication
SAaged care2008-11-06

Coroner's Finding: CECERE Rolando

71y · Male·Positional asphyxia

… facility. He had demonstrated multiple escape attempts within days of admission, with staff documenting wandering behaviour and attempts to climb fences. The facility was inadequately secured with internal doors openab…

geriatric medicinepsychiatrysystemdelay
VICcommunity2024-04-24

Finding into death of Leslie Wallace Taylor

61y · Male·head injury sustained on impact by a car

Leslie Wallace Taylor, a 61-year-old man with intellectual disability who could not communicate verbally, died from head injury sustained when struck by a motor vehicle on Ballarat Road, Sunshine on 1 October 2022. Mr Ta…

pholcodine
SAaged care2023-08-30

Coroner's Finding: Haynes, Barbara Ann

89y · Female·head injury

Barbara Ann Haynes, aged 89, died from a head injury sustained in a fall at an aged care facility on 29 March 2020, with death occurring 13 days later on 11 April 2020. She had Alzheimer's dementia, osteoporosis, and a h…

geriatric medicineemergency medicine
VICaged care2025-03-14

Finding into death of Maria Grazia Nardiello

90y · Female·Surgical repair of fractured neck of femur sustained in a fall complicated by CO…

…lity, complicated by COVID-19 infection. She was pushed by another resident with dementia and aggressive behaviour, falling in a corridor. The fracture was successfully repaired surgically, but Maria developed hypoxia a…

geriatric medicineorthopaedic surgerysystem
WAhospital2025-06-30

Inquest into the death of Houston PEEL

29y · Male·ligature compression of the neck (hanging)

… am on 30 March 2023 with acute psychotic symptoms including auditory and visual hallucinations, bizarre behaviour, and paranoid ideation following return from Bali. He was triaged as ATS 3 and assigned a 30-minute targ…

emergency medicinepsychiatrycommunicationdelayolanzapine
VICaged care2013-12-18

Finding into death of Caterina Montalto

76y · Female·Immersion (with underlying cause undetermined in circumstances of a fall into a …

76-year-old woman with vascular dementia and wandering behaviour was found submerged in a courtyard water fountain at an aged care facility after a fall. She r…

geriatric medicinegeneral practicecommunicationsystemdiazepam

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