Abstract: On November 16, 2006, Employee #1 was an inmate, applying drywall compound to walls of the PIA Division Office Conference Room. He was using a rolling scaffold, with one plank at the 4-ft level. The scaffold rolled when he stepped down, causing him to lose his balance. As he fell, his foot became caught in the top bar of the scaffold, which caused him to flip over backwards and strike the back of his head on the floor. Employee #1 was treated in the CMC Emergency Room for a blunt force head trauma injury to the back of the head, and lacerations to his hand, left elbow, and nose. He was hospitalized at Sierra Vista Hospital, where he was comatose, intubated, became decerebrate, and had a CT scan. Employee #1 had craniotomy surgery and evacuation of a hematoma. After surgery, he remained comatose and breathing with a ventilator, until his death on November 27, 2006.