"Mr East was not being watched as he showed little motivation to move from his bed without assistance."
Coroner McElrea said in his findings that Mr East was last checked at 3am. He should have been checked within the next hour and prior to the registered nurse going on her meal break at 4.30am, but was not found until 5am.
Coroner McElrea said he had no formal recommendations as he was satisfied that the Southern District Health Board had taken appropriate steps to implement recommendations which arose from a serious review event report.
A new 'intentional rounding' initiative was being developed to ensure that patients' key care requirements were checked regularly and the hospital's Reducing Harm from Falls policy had also being updated, he said.
The second falls-related death occurred on September 6, 2012 at Christchurch Hospital, when Valerie Joan Hepburn, 76, died following a series of falls at Timaru Hospital the month before. She also had a history of falls at home.
Coroner McElrea said in his findings that at the time of Mrs Hepburn's admission, Timaru Hospital had systems in place to identify fall risks in patients which was applied to her.
However, on analysis following her death, Timaru Hospital identified contributing factors including an unacknowledged high likelihood of Mrs Hepburn falling, under-reported and unrecognised increasing confusion, and compromised patient surveillance.
Mrs Hepburn's final fall occurred at a time of reduced staffing and when a number of other activities were occurring, the findings stated.
The South Canterbury DHB's falls policy had been improved following Mrs Hepburn's death and a decrease in falls resulting in injury had been noted as a result, Coroner McElrea said.
He subsequently released no formal recommendations.
The third death occurred on March 29, 2011, when Norman Raymond Henderson, 78, died at Timaru Hospital.
In his written findings, Coroner McElrea said Mr Henderson was admitted to the hospital seven days before he was heard falling from his bed in the surgical ward.
Mr Henderson suffered a large graze and a substantial cut to his lower lip and was put back to bed about 4am. However at 6.45am he was found to be unresponsive.
An investigation into the fall carried out by the hospital found that although a falls prevention plan was in place at the time, management guidelines relating to to monitoring following a fall were not followed.
Coroner McElrea said in his findings that due to the action already taken by South Canterbury DHB, he would make no formal recommendations.
