A 92-year-old man died from heart failure aggravated by injuries sustained when falling from a chair that has since been deemed not fit for use, a Coroner’s findings revealed.
Alan John McKenzie suffered chronic obstructive airways disease, Alzheimer’s Disease and dementia.
He became a resident of the Fred French Nursing Home at Newstead in June 2017 and his wife Anne visited him every day.
By November of the same year, Mr McKenzie was unable to stand or walk without assistance so he was given a princess chair to help him move around.
Mr McKenzie fell head first from the chair after leaning on its armrest while watching TV with other residents on April 14, 2018.
Mr McKenzie sustained cervical spine fractures with an epidural haematoma and spinal cord compression.
Due to his age, injuries and deteriorating health, Mr McKenzie was not able to have surgery and was returned to the home for palliation.
He died at 5.45am on April 15. Coroner Rod Chandler investigated the events leading up to Mr McKenzie’s death and a report was released on Tuesday.
McLean Healthcare technician Aaron Dilllon examined the princess chair at the request of Tasmania Police, who oversaw the investigation.
He found the rear brake was not working, the right armrest was difficult to release because of a stripped thread and the spring mechanism was worn and not properly lubricated, the right armrest also didn’t lock into the upright position properly and the left leg was missing a bolt.
“It was Mr Dillon’s opinion that the chair should have been removed from use until fully repaired,” the report said.
In his findings, Coroner Chandler said the evidence made it apparent that the princess chair was not fit for use and should have been removed from service prior to Mr McKenzie’s fall.
“The fact that it was not removed from use demonstrates very serious shortcomings in the home’s systems concerning the regular inspection of equipment, the reporting of faults and the carrying out of repairs,” he said.
“I am satisfied that Mr McKenzie’s premature death was a direct consequence of the right armrest to his princess chair collapsing when he leaned on it causing him to fall to the floor.”
Coroner Chandler recommended the home, as a matter of urgency, review protocols around the regular inspection, maintenance and repair of equipment and its fault-reporting procedures.