UPDATE Wednesday 5pm: The Department of Health and Human Services has responded to a coroner's findings in relation to the preventable death of a man in Bendigo.
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The 76-year-old died in hospital after paramedics discovered him at home with a severely broken leg.
The man, who had an intellectual disability, had had a scheduled visit the day before, but DHHS workers were unable to make contact with him.
Coroner Simon McGregor questioned why the workers did not take further steps to conduct a welfare check after failing to speak to him.
A DHHS spokesperson said the department was distressed to learn of the man's death.
"The Department takes welfare checks for our disability clients who live independently very seriously," the spokesperson said.
"We welcome the coroner's suggestions for improvements to processes for disability clients."
EARLIER: A coroner has questioned why Department of Health and Human Services employees did not make a greater effort to check on a man with an intellectual disability, who broke his leg at home and later died.
The 76-year-old Bendigo man died from hypothermia and multi organ failure last July after suffering the injury at his home, where he lived independently with twice-weekly visits from a DHHS carer.
His death in hospital came the day after his scheduled visit with his carer, during which there were several unsuccessful attempts to make contact with him.
The man's long-term carer was off sick and emailed his supervisor his appointments, including that with the deceased man.
No one was rostered on to replace the carer, so no one visited the man.
The supervisor called, but the man did not answer; however, this did not cause concern as she had been unable to reach him in the past and on that occasion he told her he had not heard the phone ring.
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The following day, the carer was informed the man was critically ill at Bendigo Health.
Paramedics had attended his home after someone reported hearing moans and found him with a broken leg, but his organs began failing and he died at hospital.
In her statement, the carer's supervisor said she tried to call the man several times during the day with no answer, but this did not worry her as he was known to go out often.
She said she sent another carer to check on him and they received no response, but again this was not a concern.
The supervisor said it was determined everything had been completed as per procedure.
But coroner Simon McGregor said the failed attempts to contact the man should have raised concern, especially because the man was always home for his scheduled appointment with his carer.
Mr McGregor said he appreciated DHHS workers in rural areas often had limited resources and greater logistical challenges, but he took issue with the fact an adequate welfare check was not conducted when every attempt to contact the man had failed.
It would not have been an "unreasonable stretch of resources" to call paramedics or police to check in on the man, the coroner said, a decision that could have saved his life.
"Therefore, although I consider [the man's] death to have been a preventable death, I intentionally refrain from making any finding or comment about whether the welfare check oversight had any causative role in the death," Mr McGregor said.
DHHS has been approached for a response.
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