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Resident falls in aged care – important findings from the State Coroner

By Julie McStay16 Sep 2014

A recent coronial decision following the death of a resident in a residential aged care facility raises some issues that will be of interest to providers about the need to contact the resident’s doctor after a fall. The decision also serves as a timely reminder of the important role of effective policies and procedures.

In this decision, the Western Australian Coroner investigated the care provided to the resident after a series of falls.

This article examines the findings made by the coroner in relation a facility’s policy to contact the treating doctor after a resident fall.

The resident was admitted to the facility on Christmas Eve, on Christmas day she sustained three falls. On each occasion, a nurse assessed the resident. She had no apparent injuries after the first two falls but after the third fall, the nurse observed a bruise on her head. The facility did not call the doctor and this was the main issue that was the focus of the Coroner’s inquiry.

The resident was transferred to hospital and underwent surgery the next day, approximately 16 hours after the third fall. The resident subsequently passed away.

Coroner’s findings and recommendations

At the time of the incident, it was the facility’s policy to call a doctor to assess a resident after a fall if the resident had an observable injury. Despite the resident’s head injury, and contrary to facility procedure, the Coroner found that the staff:

  • Did not call a doctor to examine the resident.
  • Failed to properly record the circumstances of the third fall in the resident’s progress notes.
  • Did not appropriately communicate the resident’s injuries during handover.
  • Failed to undertake further observations or assessments despite the resident’s observable injuries.

While it was acknowledged by the Coroner that the management of residents who are at risk of falls can be difficult, the Coroner found that in this case the facility had failed to provide the resident with an appropriate level of care.  The Coroner held that had the staff followed facility policy, they would have called a doctor to assess the resident and the resident would have received the appropriate treatment and care. 

The Coroner ultimately found that the death of the resident was not directly related to care received at the facility, but noted that there were deficiencies in the implementation of the facility’s falls policy, handover procedures and communication of important information between staff.


As a result of the incident, and by the time the matter came before the Coroner some four years later, the facility had reviewed their systems, policies and procedures. Some of the changes made included:

  • Amending their falls management policy to provide that a doctor be called to assess a resident after every fall regardless of whether there is an observable injury. 
  • Implementing formal handover procedures requiring all staff to have written handover notes, ensuring that each staff member is informed of those instances where residents have fallen.
  • Updating and improving their record keeping procedures and programs.

In this case the facility made an independent decision to amend their falls management policy so that a GP is notified after every fall.  Implementing a similar policy would be a conservative approach and whilst the message communicated by the Coroner was that all providers should follow suit, there are practical barriers to a policy that requires every fall be reported to the resident’s doctor.  

Following on from the Coroner’s findings, we would suggest that a minimum you review your fall management procedure taking into account the following:

  • What type of staffing do you have in your facility? Ideally a registered nurse should undertake an examination (including neurological observations) of any resident who has had a fall and that examination should be undertaken as a matter of urgency. If you don’t have an RN on duty for all shifts do you have suitable arrangements in place to ensure an appropriate assessment is undertaken as soon as possible after the fall, no matter when it occurs? 
  • The facility should notify the doctor when the resident has an injury after a fall. The doctor should decide whether he/she should attend or the resident should be transferred to hospital or whether the resident can be managed at the facility by the care staff.  Do you have a process in place to cover those instances where the incident occurs after hours and the resident’s GP is not available?
  • If the resident has a head injury the doctor should be notified and he she/should be asked to attend or in serious cases the resident should be immediately transferred to hospital. Again, what is your process to cover those instances where the incident occurs after hours and the resident’s GP is not available? If the GP is not available (or available to advise even by phone) the most conservative approach would be to transfer those residents to hospital for assessment.
  • Clinically, neurological observations are to assess a resident with a head injury.  While neurological observations are important, so is the rest of the clinical assessment by the RN.  Registered staff ‘knowing’ the resident probably forms a large part of the assessment, particularly given the complexities of assessing someone’s cognitive status with dementia, etc.   Do you have arrangements in place to ensure that someone who 'knows' the resident is also consulted as a part of the assessment?

The best approach in deciding the content of your policy is to discuss the content of the policy with the medical staff and clinical team and document a policy that the multi-disciplinary team has agreed to and that can be implemented on the basis of the staffing in place at your facility without any compromise to the resident.

The decision emphasises the importance having the appropriate policies and procedures in place (i.e. in falls management and handover) and ensuring that staff are appropriately trained in the policies and that the policies are actually followed.

Hynes Legal is specialist legal advisor to the aged care industry. We can assist providers with staff training programs, regulatory compliance, policies and procedures and critical incident management. If you need assistance in undertaking a review of your policies and procedures, we are happy to help. If after having reviewed your policies and procedures an incident occurs you will at least be in a good position to demonstrate to the appropriate authorities the efforts that you have made to prevent such an incident occurring. 

Many thanks to Julie Purcell for her input on the clinical issues addressed in this article. Julie Purcell is a nurse advisor who acts as a consultant to the aged care team at Hynes Legal on clinical matters. 

For more information, please contact us.