Abstract: Between 8:00 and 8:15 a.m. on September 1, 1994, Employee #1 was entering a building via the employee entrance steps when he fell backward, striking his head against the ground. Employee #1 was treated by physicians for abrasions and a fractured left arm and elbow. Physicians placed a cast on the fractured arm and elbow and released Employee #1 in the care of his nephew. A skull x-ray was never taken. On September 2, 1994, Employee #1 was incoherent and died while being transported to the hospital by Medi-Vac helicopter. An autopsy by the County medical examiner determined the cause of death was a fractured skull. The fatality, which was listed as job-related, was investigated by the Hasbrouck Heights, NJ, area office.