COURT REPORT

remained in pain and could barely move, and slept one night in a chair, the report said.

Two days after the fall, when Wilmshurst’s family gathered for his 62nd birthday, he returned from the bathroom pale and breathing quickly, so the family called an ambulance.

Before the ambulance and fire crews arrived, the family needed to start CPR, but he died.

Charles Freeman, giving independent advice to the inquest, said a doctor at the centre ‘‘ seriously underestimated’’ Wilmshurst’s injuries, which were found in an autopsy to be a collapsed lung, bleeding in the chest, and eight fractured ribs – most of them likely to have been caused in the fall rather than CPR two days later.

‘‘The rib fractures were found to be multiple with some penetrating the chest cavity,’’ he said.

‘‘ This would have been the cause of the bleeding into the chest cavity and with his lung collapsing, which can occur some hours or days after the original injury.’’

These issues could lead to heart attacks, he said.

In his finding, Smith said Wilmshurst died on December 28 from accidentally sustaining a blunt force chest injury, but also pointed to failings by the centre.

In a separate review of the case, the Health and Disability Commissioner had recommended that triage and documentation at the centre needed to be improved.

‘‘I echo these sentiments and I accept that [the centre] has taken steps to rectify that, but I do believe it needs to go further,’’ the coroner said.

He agreed with Freeman that Wilmshurst’s pulse and respiratory rate should have been recorded when he visited the centre, that not enough time was taken to look into what happened when he fell, and that a chest X-ray should have been taken.

The centre needed better signage to say it was an accident and medical centre, not an emergency department, Smith said.

A health board spokeswoman said earlier recommendations by the Health and Disability Commissioner had been implemented.

The commissioner’s report said nursing triage and documentation for patients in similar situations to Wilmshurst’s needed to be improve.