Coroners Act 1995
Coroners Rules 2006
Rule 11

I, Robert Pearce, Coroner, having investigated the death of

William Vernon BROOKS



(a) The identity of the deceased person is William Vernon Brooks, born 10 October 1931 at Mathinna;

(b) Mr Brooks died on 5 March 2012 in the Launceston General Hospital;

(c) The cause of his death is acute subdural haematoma suffered in a fall;

(d) No other person contributed to the cause of Mr Brooks’ death.


1. Until about a month before his death on 5 March 2012 William Vernon Brooks, aged 80, lived with his wife Gillian Brooks in St Helens.  He appeared fit and well although he suffered from and was medicated for heart disease.

2. The coronial investigation of Mr Brooks’ death has included, amongst other things:

(a) a post mortem examination conducted by Forensic Pathologist Dr Donald Ritchey;

(b) thorough review of the records of the Launceston General Hospital (“the LGH”);

(c) advice in conference from a senior nurse investigator engaged by the Coronial Division, the director of Statewide Forensic Medical Services, Dr Christopher Lawrence and Dr Ritchey.

3. On 19 January 2012 Mr Brooks presented to his general practitioner in St Helens with abdominal pain.  He underwent surgery in the LGH to remove an appendiceal abscess.  He remained in hospital for 12 days until he was discharged on 31 January 2012 when he returned to St Helens.  However according to Mrs Brooks he was still unwell and he re-presented to his general practitioner on 4 February 2012 with abdominal pain.  He was assessed and diagnosed with a small bowel obstruction and returned to the LGH.  He was taken to theatre on 7 February 2012 for a laparotomy, division of adhesions and a small bowel resection.

4. While in hospital Mr Brooks remained unwell.  He had an elevated temperature and was confused and disoriented.  He frequently tried to climb over the rails of his bed.  He was given antibiotic therapy and medication for heart arrhythmia and agitation.  Throughout the course of his admission Mr Brooks’ mental status fluctuated.  His delirium seemed to come and go and accordingly he was challenging to treat.

5. An assessment conducted by hospital staff on 14 February 2012 disclosed that Mr Brooks had a high risk of falling.  Strategies were introduced to address this.  However Mr Brooks’ general health did not improve.  At 6.30pm on 28 February 2012 Mr Brooks fell from his bed.  He hit his head and suffered lacerations to his forehead and right elbow.  His condition was assessed and monitored.  He remained stable but his delirium and confusion continued until on 1 March 2012 he seemed to improve.  He was mobilised with assistance and was eating and drinking and was transferred to a different ward.  His improvement seemed to continue the following day.

6. However early in the morning of 3 March 2012 the nurses heard a loud sound and found that Mr Brooks had again fallen from his bed.  The notes indicate that at the time the bed rails were up and the urinal and nurse call bell were within Mr Brooks’ reach.  He had been checked 10 minutes earlier.  In the fall he suffered a laceration to his right eyebrow, left hand, right elbow and wrist and a conclusion was drawn that he had hit his head on the side of the bed.  Observations taken soon after the fall revealed no particular abnormality.  However late in the afternoon of that day Mr Brooks developed an inability to speak and right sided paralysis.  An urgent CT scan was undertaken which disclosed a subdural haemorrhage.  Mr Brooks died early on 5 March 2012.

7. A post mortem examination conducted by Dr Ritchey confirmed the cause of death as acute subdural haematoma caused in the fall on 3 March 2012, contributed to by ischaemic heart disease, emphysema, small bowel obstruction and therapeutic anti-coagulation medication.  Mr Brooks received anti-coagulation medication for heart disease which increased the risk of developing bleeding complications due to otherwise relatively minor injuries.

Comments and recommendations

8. By s28 of the Coroners Act a coroner investigating a death is required to find, if possible, when and where the person died, how the death occurred, the cause of death and to identify any person who contributed to the cause of death.  It is proper that an investigation should identify not only the direct means or mechanism of death but also the circumstances attending the death.

9. The primary focus of an investigation is to seek out and record the facts concerning the death of a person.  It is a fact finding exercise of an inquisitorial nature.  The facts which are relevant are those which may enable findings about the matters the Act requires the coroner to, if possible, determine.  It is not the function of an inquest to attribute any moral or legal responsibility or liability for a death or to hint at blame.  It is not a means of apportioning guilt.  A coroner is to determine facts.  The facts, once determined, will speak for themselves and it is for others to, if necessary, draw legal conclusions.

10. In the course of the investigation Mrs Brooks raised some concerns about the treatment of her husband while in hospital.  Whist her concern is natural and understandable given the increasing health difficulties Mr Brooks experienced, I am not satisfied that the manner of his treatment affect any of the findings I am required, as coroner, to make.  I find that his treatment in hospital did not contribute to the cause of his death.

11. Mrs Brooks also pointed out that she ordered a restraint for her husband while in hospital, to reduce the risk of falling.  I do not intend to make a finding or comment about the lack of restraint at the time of the fall.  It is unnecessary that I do so.  On the face of it the authority did not direct that he be restrained but, rather, simply permitted the application of a restraint if those responsible for his care thought it necessary to apply it instead of adopting other measures.  It is open to Mrs Brooks to raise that or other issues concerning his care in another forum if she wishes to do so.

12. I have decided not to hold in inquest into Mr Brooks’ death.  The investigation has sufficiently disclosed the identity of the deceased person, the time, place, the relevant circumstances concerning his death and the particulars needed to register his death under the Births, Deaths and Marriages Registration Act.  No other a person contributed to the cause of Mr Brooks’ death within the meaning of that term in the Coroners Act 1995.  I do not consider that an inquest is likely to elicit any further significant and relevant information concerning the issues that I am required to determine.

13. There is no need in this case to make any other comment or recommendation.

I convey my sincere condolences to Mrs Brooks and Mr Brooks’ family.

DATED: 18 September 2012 at Launceston in Tasmania.

Robert Pearce