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Coroner's Finding: Wright, Ronald James

Deceased

Ronald James Wright

Demographics

81y, male

Date of death

2024-02-05

Finding date

2024-09-19

Cause of death

Pulmonary thromboembolism as a result of multiple traumatic injuries caused by accidental fall from height

AI-generated summary

An 81-year-old man fell from a 2.8-metre ladder while installing a sunshade on his roof. He had not secured the ladder or had a spotter present. The ladder overbalanced when he attempted to stand on the top rung, which bore a warning label. He sustained multiple traumatic injuries including skull fractures, brain contusions, subdural haematoma, subarachnoid haemorrhage, and pelvic and arm fractures. After 12 days of intensive care complicated by delirium, he developed a pulmonary thromboembolism and died. The coroner emphasised that ladder safety, particularly for older workers, is critical and that this preventable death highlights the ongoing risk of unsafe ladder use among elderly males.

AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.

Specialties

trauma surgeryintensive carepalliative care

Error types

system

Contributing factors

  • Unsafe ladder use at age 81
  • Failure to secure ladder feet
  • Absence of spotter or second person
  • Standing on top rung despite warning label
  • Ladder overbalance during foothold adjustment
  • Working at significant height (2.8 metres)
  • Post-traumatic delirium during recovery
Full text

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Record of Investigation into Death (Without Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Olivia McTaggart, Coroner, having investigated the death of Ronald James Wright Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is Ronald James Wright, date of birth 5 August 1942.

b) Mr Wright was 81 years of age, was a retired sawmiller and salesman, and lived with his partner in Mowbray. He has two children from previous marriages. On 24 January 2024, Mr Wright used a 173-centimetre A-frame aluminium ladder to erect a sunshade on the roof of his house. He was working at a height of 280 centimetres. Mr Wright had not taken steps to properly secure the feet of the ladder or to have another person present when he was working. As he was working on the ladder at the height of the roof, the ladder overbalanced when he attempted to obtain a foothold on the top rung. The top rung displayed a partially erased sign, cautioning the user of the ladder to not stand on that rung.

Unfortunately, Mr Wright fell to the concrete patio below. His fall was captured on the home closed-circuit television system.

Shortly after his fall, his partner found him conscious, in pain and bleeding from the head. An ambulance was called, and he was conveyed to the Launceston General Hospital. In hospital, he was assessed as having numerous injuries. These included skull fractures, brain contusions, subdural haematoma, subarachnoid haemorrhage, fracture of the right humerus and fracture of the pelvis. He was airlifted to the Royal Hobart Hospital for specialist intensive care treatment. He remained an inpatient for twelve days but his recovery was complicated by delirium. On 4 February 2024, there was a dramatic deterioration in his condition because of the development of a pulmonary thromboembolism. He subsequently underwent multiple medical reviews by the trauma team but, due to his very poor prognosis, he was transitioned to palliative care in consultation with family. He passed away on 5 February 2024.

c) Mr Wright’s cause of death was pulmonary thromboemboli (blood clots in the arteries of the lungs) as a result of multiple traumatic injuries caused by his accidental fall from a height.

d) Mr Wright died on 5 February 2024 at Hobart, Tasmania.

In making the above findings, I have had regard to the evidence gained in the investigation into Mr Wright’s death. The evidence includes:

• The Police Report of Death for the Coroner;

• Tasmanian Health Service Death Report to Coroner;

• Affidavits verifying identity;

• Opinion of the forensic pathologist regarding cause of death;

• Affidavit from Penny Frank, partner of Mr Wright;

• Affidavit and photographs of a Forensic Services police officer; and

• CCTV footage from the scene.

Comments and Recommendations It was inadvisable for Mr Wright, at 81 years of age, to work at a height from a ladder, and particularly inadvisable not to use it safely.

Over recent years, Coroners have emphasised in numerous findings that older males using ladders unsafely have resulted in preventable deaths. Tragically, Mr Wright’s death is another such case.

I convey my sincere condolences to the family and loved ones of Mr Wright.

Dated: 19 September 2024 at Hobart, in the State of Tasmania.

Olivia McTaggart Coroner

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