Coroner's Finding: Bird, Allan Roy

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 Allan Roy Bird Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is Allan Roy Bird, date of birth 23 December 1931.

b) Mr Bird was 92 years of age and, since 23 May 2024, he had been a resident of Fairway Rise residential aged care facility (“RACF”) operated by Southern Cross Care (Tasmania) Inc. On 14 August 2024, Mr Bird had an unwitnessed fall in his room which resulted in a left hip fracture. He had surgery to fix the fracture at the Royal Hobart Hospital but declined with delirium postoperatively. He was transferred back to the RACF, and, with family approval, palliative care was administered until he passed away.

c) Mr Bird died as a result of the consequences of his accidental fall at the RACF, these being post-operative delirium, left femoral intra-medullary nail insertion and a left neck of femur intertrochanteric fracture. His age-related frailty, coronary artery disease, hypothyroidism and atrial fibrillation contributed to his cause of death.

d) Mr Bird died on 22 August 2024 at Lindisfarne, Tasmania.

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

• The Police Report of Death for the Coroner;

• Affidavits confirming identity;

• Opinion of the forensic pathologist regarding cause of death;

• Records, report and Root Cause Analysis from Southern Cross Care;

• Medical Records from the Royal Hobart Hospital;

• Falls Review Report by Angela Duncan, Coronial Nurse; and

• Medical review by Dr Anthony Bell MD FRACP FCICM, Coronial Medical Consultant.

Comments and Recommendations Upon the evidence in the investigation, there were missed opportunities in the care and assessment of Mr Bird at the RACF that put him at increased risk of his fall. Before his fall, Mr Bird had been assessed as being at a low falls risk with insufficient, clearly documented falls prevention strategies being in place.

The evidence indicates that the following matters should have been considered in implementing fall prevention strategies:

• The fact that Mr Bird was 92 years of age. This factor alone would have put him at increased risk of falling due to sarcopenia or the loss of skeletal muscle mass and strength due to ageing.

• The fact that Mr Bird was taking three prescribed medications, including a benzodiazepine, that put him at increased risk of a fall and life-threatening complications of a fall.

• That Mr Bird was documented as being prone to impulsivity, especially in relation to his decisions concerning mobility. He often did not use his mobility aid.

• That a formalised and comprehensive care plan should have been put in place when Mr Bird transitioned from being a respite patient to being a permanent resident of the facility.

• That a further falls risk assessment should have been conducted in response to Mr Bird’s functional decline before his death.

If the above matters had been properly considered or completed, Mr Bird may have had the benefit of additional or more clearly documented falls prevention strategies. Additional measures for consideration may have included increased staff supervision, bed sensors and the offer of hip protectors.

I recognise, of course, that even if Mr Bird’s falls risk had been properly recognised and mitigated, he may well still have fallen and suffered fatal injuries due to his tendency to mobilise without calling for assistance or without his mobility aid.

I also acknowledge that the RACF, in its Root Cause Analysis, has recommended several measures to ensure rigorous falls assessments and prevention strategies for residents. If these recommendations have not already been implemented, they should be completed without delay.

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

Dated: 7 January 2026 at Hobart, in the State of Tasmania.

Olivia McTaggart Coroner