To view this page correctly you must have Chinese characters installed.

Recent Coroner's decision emphasises need to ensure Falls Policies are updated

18 Aug 2016

South Australian Coroner’s findings

The Department of Health (Department) has released an Industry Feedback Alert in response to the South Australian Coroner’s recommendations regarding aged care residents on anticoagulant therapy and falls resulting in head injuries.   

Although the Coroner’s findings are not legislative requirements the Department stated in its alert that providers should:

  • read the Coroner’s report
  • make their key personnel aware of the information
  • take appropriate action

The Coroner’s report states the facility involved in the inquest acted according to the normal standard of care in response to a resident’s fall in a residential aged care facility. However in light of the issues raised the Coroner took the opportunity to make relevant recommendations. 

For details of the circumstances surrounding the resident’s death, click here.

The Coroner recommended residential aged care providers implement a policy that requires all residents who suffer a head injury in a fall, including a minor head injury, be sent to the hospital for assessment.  The Coroner also recommended that if the resident is on anticoagulation therapy, the hospital must consider conducting a CT scan.

Prudent providers will take action in response to a Department alert.  Providers should, therefore, consider amending their falls policy in light of the Coroner’s recommendation regarding hospital referral.  Many providers would regard it as impractical to require that every resident who falls and has a minor head injury has to be transferred to hospital.  It would, in our view, be a reasonable compromise to implement a policy that requires that every resident who suffers any head injury in a fall, including a minor head injury, must immediately be assessed by a Registered Nurse (RN). The RN must commence neurological observations and make a decision as to whether the resident needs to be transferred to hospital.  This would reasonably be coupled with a requirement that the RN consult with the GP and that the GP attend and assess the resident.

The Coroner also noted that the aged care facility involved in the inquest adopted a policy that any resident subject to anticoagulation therapy ‘must’ be sent to the hospital for assessment following a fall resulting in a minor head injury.  This was an internal policy decision and the Coroner did not include this in his recommendations.  However, since the issue has been raised by the Coroner a prudent provider should consider adopting a similar requirement.

The Coroner also made some fairly damning comments about the actions of an agency nurse who failed to carry out appropriate observations of the resident.  The case is also, therefore, a timely reminder of the importance of ensuring a rigorous induction process is in place before allowing agency staff into your facility. 

If you require advice in relation to the content of your falls policy, please contact Julie McStay Director - Aged Care and Retirement Living, Hynes Legal for further information.

This content is not intended to be a substitute for legal advice.


  • The resident (Mrs Ford) died as a result of acute left subdural haemorrhage aged 84 years
  • She was a frail aged lady with dementia, she could not walk without assistance (required full hydraulic lift) but could get up out of a chair
  • She was a high falls risk
  • Mrs Ford was on warfarin anticoagulant treatment with a history of Deep Vein Thrombosis episodes
  • Mrs Ford suffered an unwitnessed fall from her chair while under general observation in an area where staff were frequently passing in and out
  • Staff arrived quickly on the scene after Mrs Ford’s fall and she was assessed and observed by the RN
  • Following the RN’s initial assessment further neurological observations were attempted, however, Mrs Ford refused to permit the staff member to carry them out
  • Neurological observations  were not conducted until 4 hours later when another staff member who Mrs Ford related to was able to carry them out
  • Overnight an agency nurse failed to wake Mrs Ford and did not make neurological observations or assess her levels of consciousness.
  • The Coroner’s comments regarding the actions of the agency nurse were, “The agency nurse was forced to accept that by not waking Mrs Ford she was unable to carry out proper neurological observations and assess levels of consciousness. It is beside the point that a demented patient might be confused and find it difficult to go back to sleep. This smacks of staff convenience more than concern for the patient and reflected a compromised standard of care at the hands of this agency nurse.
  • Expert medical opinion in the inquest stated that Mrs Ford’s anticoagulant therapy was managed well in the aged care facility however, risks of haemorrhage are greater for residents such as Mrs Ford.
  • Expert medical opinion provided that residents with pre-existing cognitive impairment have a lot of cerebral shrinkage, and this means that it is often difficult to detect intracranial bleeding until it becomes too late. And there is a greater chance for blood to accumulate (smaller brain size) because there is more space inside the skull. Hence the haemorrhage will only be found when it is quite large.


Add your comment
3 Thank you. Your comment has been received and is currently being reviewed.