Record of Investigation Into Death(Without Inquest)

Coroners Act 1995
Coroners Rules 2006
Rule 11

I, Glenn Hay, Coroner, have investigated the death of Frances Joan KNOWLES

I find that:

(a) The identity of the deceased is Frances Jean Knowles (Mrs Knowles);

(b) Mrs knowles died on 23 March 2011 at the Royal Hobart Hospital;

(c) Mrs Knowles was born in Oatlands on the 10 March 1922 and was aged 89 years at the time of her death;

(d) Mrs Knowles was widowed and her occupation at the date of death was retiree;

(e) Mrs Knowles died as a result of a subdural haematoma due to a fall from a standing position. Significant contributing factors were ischaemic heart diesase, dementia, vertigo, osteopenia and gout;

(f) At the time of her death she was not being treated by a medical practitioner.

Circumstances Surrounding the Death:

Mrs Knowles lived independently in a unit in Claremont until late November 2010 when her level of dementia required her to seek treatment at the Royal Hobart Hospital. After a period of about three weeks she was released from that hospital to the Strathglen Nursing Home in Glenorchy.

On 25 January 2011 Mrs Knowles suffered a fall in which she suffered a break to the neck of her left femur. She was conveyed to the Calvary Hospital where she underwent corrective surgery. On her return to Strathglen Nursing Home on 28 January 2011 her mobility was initially limited and she required the use of a frame.

While her mobility was improving, on 14 March 2011 Mrs Knowles suffered another unwitnessed fall at Strathglen Nursing Home. She had visible injuries to her head, elbow and right leg. As a result of this she was conveyed to the Royal Hobart Hospital by ambulance where it was discovered that she had suffered two subdural haematoma, one of them acute. From all available evidence it is most probable she had hit her head during this unwitnessed fall, giving rise to the acute subdural haematoma.

On 19 March 2013 Mrs Knowles' condition further deteriorated. It was determined that she was not suitable for further corrective surgery and, in consultation with her family, she was provided palliative care until she died whilst a patient at the Royal Hobart Hospital on 23 March 2013.

A post mortem examination, which comprised an external examination and review of clinical medical records, determined that her cause of death was the subdural haematoma to her head she received after falling from standing on 14 March 2011. Significant contributing factors were her ischaemic heart disease, dementia, vertigo, osteopenia and gout.

Other Findings and Comments:

In light of various concerns raised by the senior next of kin of Mrs Knowles, a thorough and extensive investigation into her death has included review of all clinical notes and files at the Calvary Hospital, Royal Hobart Hospital and Strathglen Nursing Home.

A CT scan of Mrs Knowles brain on 14 March 2011 raised the possibility of a pre-existing bleed in her brain possibly from a previous fall. My investigations lead me to firmly conclude that it is impossible to determine the age of this subdural haematoma as it could have been present and undetected for a long period of time and possibly before her admission to the Nursing Home. I am satisfied there is no reasonable link of this injury to the quality of care received by Mrs Knowles during her time at the Nursing Home.

Further, I am satisfied that the fact Mrs Knowles was not wearing 'hip protectors' at the time of her last fall is not relevant to the cause of her death, which I have found to be as a result of the injury to her head during that fall. Should the senior next of kin continue to have concerns in relation to this aspect then she should approach the Office of Aged Care Quality and Compliance.

I have decided not to hold a public inquest hearing into the death of Mrs Knowles because my investigations have sufficiently disclosed the identity of Mrs Knowles, the time, place, cause of death, relevant circumstances concerning how her death occurred and the particulars needed to register her death under the Births, Deaths and Marriages Registration Act 1999. I do not consider that the holding of a public inquest hearing would elicit any information further to that disclosed by the investigations conducted by me.

I wish to convey my sincere condolences to the family of Mrs Knowles for their sad loss.


DATED: Thursday 4 July 2013 at Hobart in the state of Tasmania


Glenn Hay