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  • Writer's pictureThe Communiqués

Residential Aged Care Communiqué Volume 18 Issue 4 November 2023


In this edition

  • Editorial

  • Case #1: Unwitnessed and unchecked

  • Case #2: Solving one problem creates another

  • Comments from senior nurses

  • List of Resources


This is the final Residential Aged Care Communiqué 2023 which presents the results of two investigations into a resident’s death due to a fall. The common underlying factor in both cases was ‘timeliness of care’. In both cases the falls were not anticipated. Both residents were under different forms of observation or checks and yet neither of the fatally injured residents were discovered by the allocated staff.


The sections ‘Reflections of senior nurses’, the editorial and detailed authors’ comments explore many of the issues. The variability in how each facility approaches resident supervision and observation requires local application of the lessons from these two cases.

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