‘Irreversible and fatal’: Coroner reveals Valma Tweedie’s fatal fall under lemon tree

An elderly Tasmanian woman with disabilities living in supported accommodation died after being left outside, alone, in the cold and rain at 3am, a coroner has revealed.

Valma Ann Tweedie, 72, died after being left outside at a Launceston disability support home. Picture: File

A woman in her seventies with an acquired brain injury was left “alone, outside, in the cold and the rain” in the early hours of the morning before tragedy struck.

In his findings released on Monday, Coroner Simon Cooper said Valma Ann Tweedie suffered a fractured spine after being left outside, unsupervised, at Launceston’s St Michaels Desmond Wood disability-support accommodation in July 2021.

She died a month later from hospital-acquired pneumonia – her spine injuries having remained undiagnosed by Launceston General Hospital for two weeks after her fall.

Mr Cooper said Ms Tweedie, 72, had an intellectual disability, attributed to an acquired brain injury, plus had significant balance and mobility problems and probable dementia – but was an “active and vibrant lady” who lived life to the full.

However, he said on July 14, 2021, Ms Tweedie was found lying on her back, on pebbles and half under a lemon tree – and was “wet and very cold” with hypothermia.

Mr Cooper said Ms Tweedie had a well-documented history of falls, which was known to St Michaels.

He said Ms Tweedie likely fell some time after 3.10am after she had gone outside for a cigarette with a staff member.

Mr Cooper said the staff member, who had left her alone after going back inside to help another resident, found Ms Tweedie about 5.45am.

Launceston General Hospital has again been found by a coroner to have delivered suboptimal care, this time relating to the death of 72-year-old Valma Tweedie. Picture: Amber Wilson

He said the worker, even if she was unaware of Ms Tweedie’s history of falls, should not have left an elderly client outside in the dark after 3am.

Mr Cooper also said in the years leading up to Ms Tweedie’s death, St Michaels “did nothing” in a practical sense to review or assess her needs for care.

“Ms Tweedie’s death was, in my view, a direct result of her being left alone, outside, in the cold and the rain in the early hours of the morning completely unsupervised,” he said.

“I do not think it is unreasonable to observe that policies, procedures and protocols should not be necessary to tell anyone that an elderly lady with an acquired brain injury, symptoms of dementia and mobility and balance issues should not be left in such circumstances.”

Mr Cooper also said Ms Tweedie’s care at Launceston General Hospital was “suboptimal” due to the failure to diagnose her injuries in a timely manner.

“Nonetheless … that issue did not change the ultimate outcome for Ms Tweedie because the injury she sustained when she fell in the garden … was irreversible and fatal.”

An analysis conducted by the hospital after her death found there had been “deviations from protocols” and “environmental pressures,” meaning neurological assessments weren’t fully completed.

St Michael’s Association CEO Mike Thomas said the organisation had already undertaken measures to address Mr Cooper’s concerns – including the implementation of a new incident management system, to allow for better record-keeping and communication.

Mr Thomas said the organisation had also introduced a practice of active night supports to people temporarily housed in alternate accommodation, as Ms Tweedie was.

The Department of Health said it noted the coroner found there had been a delay in diagnosing Ms Tweedie’s spinal injury, and “the irreversible nature of this injury”.

A spokesperson said a number of changes had since been implemented, including improvements to policies, education and training to manage trauma cases.

In addition, in February this year, a statewide trauma bed-card and referral system was introduced to help manage patients with complex trauma injuries - with specialist trauma clinicians in Hobart available at all times to help colleagues in the north and north-west.

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