A coroner has found that an elderly woman who died weeks after falling from her wheelchair while travelling on an aged-care bus had not been properly secured. Kathryn Papanastasiou sustained leg fractures as a result of the fall, which was caused by the Brightwater Care Group bus driver braking suddenly as they were heading to an event at Optus Stadium on March 4, 2020. In his findings, Coroner Michael Jenkins found that the 74-year-old, who had several health issues including congestive heart failure, cognitive impairment and type-2 diabetes with neuropathy, had only been secured to her wheelchair using a shoulder strap. The Australian standard for securing wheelchair-bound passengers is either using a pelvic lap-sash (two-point restraint) or a shoulder restraint connected to a pelvic lap-sash (three-point restraint). When the driver braked, the force caused Ms Papanastasiou, who was a resident at the group’s Subiaco facility, to fall from her wheelchair. But Mr Jenkins said it was unclear if she fell despite being strapped in or if the shoulder strap was not connected properly or if it became disconnected before the accident. When the driver stopped, Ms Papanastasiou was found with her head on the foot plate of her wheelchair, while her left leg was bent, and her right leg was under the wheelchair of another resident. She was taken to Sir Charles Gairdner Hospital for treatment but following an assessment by her doctors, she was deemed unsuitable for surgery. She was then treated conservatively using splints and analgesia but over the next few days her condition slowly deteriorated and on March 11, she transitioned to palliative care. Ms Papanastasiou died a few days later on March 15. During the Coronial inquest, the bus driver gave evidence that she went to get the appropriate belt for the bus but inadvertently grabbed a lap-strap sash with the wrong connector. When she realised, she looked for the correct belt but could not find one. She then said a man who had parked behind the bus began to verbally abuse her, so she decided Ms Papanastasiou would be secure with the shoulder strap. As she was heading down Wellington Street, she checked the map application on her phone, which was secured in a cradle below the dashboard of the bus. She then looked up and saw traffic had stopped and she was forced to brake hard. Since the incident, Brightwater have updated their policies and procedures concerning the transport of residents on its buses. It has also created three new therapy assistant roles for its community access program. The assistants are also the only people allowed to drive their buses. It also fitted the vehicles with cradles for mobile phones at dashboard height and amended its policy to make it clear that when a resident is being transported in a wheelchair, that a three point restraint system (consisting of a pelvic lap sash and a shoulder strap) be used, which was one of the three recommendations made by Mr Jenkins. He also recommended to clearly label and audit its straps and amend its policy documentation to mandate annual refresher training for all staff responsible for driving vehicles used to transport residents.