SINGAPORE - A 91-year-old resident at a voluntary welfare home was doing his thrice-weekly exercise strapped to a standing frame when the straps gave way and he fell backwards, hitting his head on the floor, a coroner's court heard on Tuesday (April 4).

An inquest into the death of Mr Ng Pui Kuan heard that the wear and tear of two Velcro straps on the 10-year-old physiotherapy equipment led to a loss of tensile strength.

The standing frame had been checked two days before Mr Ng fell from the frame on Oct 10 last year at about 9.50am. He was pronounced dead at 8.54pm the same day.

A computed tomography scan showed he had sustained an extensive brain haemorrhage.

Mr Ng, who had moderate dementia, was admitted to the Bright Hill Evergreen Home at Punggol Field as the family had difficulty taking care of him. He was prone to falls, and was always in a daze due to his dementia.

His medical history included ischaemic heart disease, hypertension, anaemia and giddiness.

Closed-circuit television footage of the gym showed Mr Ng fell five minutes after the straps gave way.

None of the components on the standing frame, which is equipped with two supporting straps, had been replaced since the home acquired it in April 2006.

Its head physiotherapist noted that physiotherapist assistant Myra Endaya Selda had applied the proper technique of strapping Mr Ng on Oct 5 and 10.

But the way Mr Ng bent back on Oct 10 might have resulted in less space for the Velcro straps to overlap.

Mr Ng did his 15 to 20-minute exercises three times a week to maintain his core stability and back muscles.

During his stay, he had had six falls, including the one on Oct 10, but had not suffered any life-threatening injuries previously.

The court heard that Mr Ng was secured onto the device when Ms Selda left to attend to a commotion as other residents were fighting.

She returned shortly after to check on Mr Ng, who was leaning slightly back on his right side. She adjusted his position and checked the straps, but did not readjust them as she felt they were still secure and in place.

The standard operating procedure did not require the physiotherapy assistant to be at the side of a resident at all times, unless the resident is walking or performing bed exercises.

The home has since taken steps to implement corrective preventive measures, which include the placing of fastening buckle to supplement the Velcro straps, as well as a "back-stop" pillow to cushion any inadvertent fall, noted State Coroner Marvin Bay.

"A staff member will also be on standby at the time that exercises are done," he said in his findings.

He said Mr Ng's death is from an "unfortunate misadventure".

"Mr Ng's sad demise underscores the importance of properly maintaining and replacing worn rehabilitation and exercise equipment in care facilities. Worn components should be regularly replaced, so that the equipment can continue to reliably serve their intended function," he said.