Record of Investigation into Death (Without Inquest)

Coroners Act 1995
Coroners Rules 2006
Rule 11

I, Rod Chandler, Coroner, having investigated the death of an elderly person


Find That:

The deceased died in December 2008 at the Royal Hobart Hospital (‘the RHH’) in Hobart.

The deceased was aged 81 years and was a widow and retired at the time of her death.

I find that the deceased died as a result of acute renal failure due to a cerebral infarct and dehydration following a fractured neck of the right femur sustained in a fall.

At the time of the deceased’s death she was in the care of medical practitioners at the RHH.

Circumstances Surrounding the Death:

The deceased lived alone but was regularly visited by her family.

On a family members arrival at the deceased’s home, they found the door unlocked as usual, with the key in the lock on the inside of the door. She entered the house, and called out to the deceased but did not receive a response. She then walked into the lounge room where she found the deceased lying on the floor on her right hand side. The elderly woman was conscious but incoherent. The family member immediately summoned an ambulance using a neighbour’s telephone. She then returned to the deceased’s home to wait for the ambulance. She placed a pillow under her relative’s head and covered her with a blanket.

The ambulance arrived at approximately 1:45pm. The ambulance officer’s notes indicate that the patient had been on lying on the floor for possibly as long as three days . The patient was conveyed to the RHH. There it was considered that the patient had suffered a left middle cerebral artery stroke with right side hemiplegia causing her to fall and and fracture her hip. She was also noted to be extremely dehydrated. A decision was taken to treat the patient conservatively. She was given fluids plus morphine for pain relief, However, her condition slowly deteriorated and she was found deceased in her ward bed.

A death certificate was issued by a Doctor at the RHH, stating the cause of the patient’s death to be multi-organ failure (pre-dominantly renal) following a stroke due to atrial fibrillation. A significant contributing factor was shown as the fracture to the neck of the deceased’ss right femur. A subsequent review of this certificate by the RHH led to the deceased’s death being appropriately referred to the Office of the Coroner.

A review of the known circumstances of the patient’s death was conducted by State Forensic Pathologist, Dr Christopher Lawrence. Dr Lawrence noted the clinical interpretation made by the doctor to the effect that the patient had suffered a stroke which led to her fall. However, he considers as more likely the alternative explanation, namely ‘that she fell having fractured her hip, lay on the ground for between one and two days and possibly developed the stroke as a consequence of the dehydration and metabolic effects of lying dehydrated for 1 – 2 days.’ I accept this latter scenario to be the most probable.

I am satisfied that a thorough and detailed investigation has occurred into the death of the patient and that there are no suspicious circumstances.


The deceased’s suspected fall and the fracture of her femur necessitated her subsequent death being reported to a Coroner. The failure to initially report the death meant that the opportunity to undertake a post-mortem examination was lost. I note however, that the process of review conducted by the RHH identified this error and steps were subsequently taken to properly report the death.

It is a most unfortunate feature of this case that the deceased suffered for several days following her fall because she was unable to move to obtain assistance for herself. These circumstances provide me with an opportunity to remind those elderly persons who live alone of the obvious benefits of permanently wearing a personal alarm device which can be immediately utilised in the event of the wearer becoming incapacitated. Had the deceased been wearing such a device then the tragedy of her death may have been avoided.

I conclude by conveying my sincere condolences to the family of the deceased.

DATED : Thursday, 4 June 2009 at Hobart in the State of Tasmania.

Rod Chandler