Coroners Act 1995
Coroners Regulations 1996
Regulation 14
Form 4


I, Christopher P Webster, Coroner, having investigated the death of


(“the deceased”)





(“the deceased”) died on 19 December 2006 at the Royal Hobart Hospital, Liverpool Street, Hobart. 


(“the deceased”) was aged 88 years. He was a married man and at the time of his death was retired.


I find that (“the deceased”) died as a result of aspiration pneumonia, complicating a right frontal brain contusion which he sustained in a fall.


At the time of his death, (“the deceased”) was in the care of medical practitioners at the Royal Hobart Hospital. 



(“the deceased”) had been a resident of the St Anne’s, Compton Downs since his admission on 10 December 1996. He had a history of diverticulitis, chronic diahorrea, carcinoma of the colon and transient ischaemic attacks. He was placed in the care of St Anne’s to receive low dependency care after his recovery from his colon cancer. (“the deceased”)was also known to have occasional seizures, which were controlled through the use of prescribed medication.


(“the deceased”) had a right total hip replacement and open reduction/internal fixation of the right femur. (“the deceased”) required the aid of a wheelchair after the removal of the right hip prothesis in 2000. He was subsequently provided with a wheelchair by St Anne’s of which the maintenance was the responsibility of the home. 


At around 11.30am on 1 December 2006, staff went to the room of (“the deceased”) to get him for lunch. On entering the room (“the deceased’s”) wheelchair was located empty and was near the bathroom door facing back toward his bed. An arm then appeared over the side of the bed, where (“the deceased”) was found on the floor beside his bed with his head between his bed and the armchair.


(“the deceased”) was bleeding from a wound to his head and also from his nose. He appeared to be panicky, upset and nervous and at one stage allegedly grabbed out at one of the staff attempting to assist him. Staff attempted to make (“the deceased”) as comfortable as possible, however while he was on the floor he appeared to suffer from a number of seizure type episodes.


Ambulance personnel arrived and conveyed (“the deceased”) to the Royal Hobart Hospital (RHH).


A CT scan was conducted which identified a right frontal lobe contusion. (“the deceased”) was treated conservatively whilst in the RHH. During his time in the RHH he developed chest pain, became increasingly frail and developed pneumonia which was complicated by atrial fibrillation.


(“the deceased’s”) level of consciousness deteriorated and active treatment was withdrawn and he unfortunately passed away at 1.35pm on 19 December 2006.


An external examination and review of medical records was undertaken by the Pathologist who ascertained that the cause of death was aspiration pneumonia, complicating a right frontal brain contusion which he sustained in a fall.


There is some suggestion that (“the deceased”) may have fallen from his wheelchair when attempting to get into or out of his bed and striking his head in the fall. This is most likely, but without a witness to the incident one can only speculate as to what actually occurred.


There has also been the suggestion that the condition of (“the deceased’s”)wheelchair may have been a contributing factor in his death. I note that an independent examination of the wheelchair was undertaken which revealed the following:


Ø      the brakes were intact but not adjusted properly to effectively mobilise the chair;

Ø      front castor wheels were moving freely with axle and swivel movement ok and within operating standards;

Ø      tyres were bald and needing replacement. The wheel structure, spokes, rim, bearings and hand rim were all ok, to standard;

Ø      footplates look brand new compared to the rest of the chair showing very little use. They were both in good condition and to standard;

Ø      the frame of the chair has been damaged. The seat, steel tubing where the seat is attached is bent. Considerable force would have applied to bend the tubing; and

Ø      in summary, the chair shows a definite lack of maintenance. Apart from the chair having bald tyres and ineffective brakes, it was filthy dirty. To bend the steel tubing on the seat would have required a considerable force to do that kind of damage.




I am satisfied that there are no suspicious circumstances surrounding the death of (“the deceased”).


I am unable to ascertain from the evidence available to me if the condition of (“the deceased’s”) wheelchair was a factor which contributed directly to his death. I am however concerned as to the state of the wheelchair, bearing in mind it was used by (“the deceased”) as his principal seat when he was out of bed. 


It is imperative that where a person requires an aid to assist in their mobility or comfort that all efforts are made to ensure that, this mobility or comfort is not restricted. It is also of utmost importance that the person’s safety remains uncompromised and that everything that can be done is done by those in a position of providing care to make sure that such equipment is appropriately maintained to ensure that the safety of the person is not in any way diminished.  


Whilst I am concerned as to the condition of (“the deceased’s”) wheelchair at the time of his fall and the responsibility of it’s maintenance by St Anne’s, my findings are that there is no firm evidence to directly connect the lack of maintenance of the wheelchair or the wheelchair in general to his death. I am simply highlighting that where there is the need for equipment to be supplied, the duty of care is to ensure that the equipment is maintained to an expected standard where safety will not be compromised.


I find that (“the deceased”) died at the Royal Hobart Hospital on 19 December 2006 as a result of aspiration pneumonia, complicating a right frontal brain contusion which he sustained in a fall, which was most likely from his wheelchair. 


I wish to conclude by conveying my sincere condolences to the family of (“the deceased”). 


DATED: Friday, 11 May 2007 at Hobart in the State of Tasmania.  




Christopher P Webster