NSW Deputy Coroner: nursing homes must review deaths

Following her inquest into a death in a nursing home, the NSW Deputy Coroner wants the whole residential care sector to learn the lessons.

Above: Ross Low, Chief Executive Officer of Baptist Community Services.

By Stephen Easton

The NSW Deputy State Coroner has come down on one of the state’s biggest non-profit aged care providers over the death of a resident in 2009 and in doing so, made recommendations that could affect all residential aged care providers.

The inquest, which concluded on Friday 20 May, found that Iris Conyngham died as a result of a fall she suffered at the Shalom Centre for Aged Care in Marsfield, Sydney, where she had been admitted as a resident only an hour earlier.  

The Deputy State Coroner, Magistrate Carmel Forbes, strongly criticised the facility’s owner, Baptist Community Services (BCS), for failing to investigate the death or even record that it had happened, and the nurses involved for both the quality of the care they provided and their reliability as witnesses.

Ms Forbes recommended that the NSW Nurses and Midwives Registration Board review the professionalism of the care provided by the registered nurse on duty, and that the Department of Health and Ageing (DoHA) look into the response from BCS. 

In an especially wide-ranging recommendation, she suggested that DoHA require all aged care facilities to “undertake a root cause analysis of all deaths and hospitalisations that occur following a traumatic event within the facility”.

“Certainly I could not find anything that has been done to look at how this situation arose and it follows that no consideration has been given to ensure it doesn’t happen again,” Ms Forbes said.

But according to a written statement made by BCS in response to the findings, the organisation has implemented a range of important changes since the death in 2009, aimed at ensuring the care their residents receive “continues to be of the highest standard possible”.

These include the introduction of critical incident investigations, conducted after what the provider calls “significant events”, followed by case reviews that go over the findings of the investigations with management staff.

At the Shalom Centre itself, BCS has employed an ‘admission nurse’, increased clinical management staff from two to three, introduced falls management instructions and purchased 16 new floor-level beds that drastically reduce the danger of falling out of bed. These models now account for 25 per cent of total beds at the facility.

In a separate written statement in response to the inquest, BCS expressed regret for the death and accepted the Deputy State Coroner’s findings and recommendations, and saying it would implement all recommendations made by DoHA.

According to BCS CEO, Ross Low, the provider welcomes the opportunity to review the incident with DoHA and will cooperate fully during the process, which has already begun. BCS has already contacted DoHA in relation to the the inquest.

“BCS is committed to learning from this tragic incident and as a leading Christian care organisation, the health, safety and wellbeing of our clients is of paramount importance to us,” he said.

“As a Christian care organisation which highly values openness and transparency, BCS has taken a number of proactive steps to enhance its safety and care practices.” 

In terms of individual BCS staff members, the registered nurse on duty at the time bore the brunt of the Deputy Coroner’s wrath, in particular for failing to provide full and open testimony to the inquest but also for her decision to give Mrs Conyngham a cup of tea, in contradiction to instructions on her hospital discharge papers.

“[The RN on duty] was not an open, clear, consistent witness and I would not describe her evidence as reliable,” Ms Forbes said, rejecting some of the nurse’s evidence that differed from the progress notes she made at the time. 

The new CEO of Aged and Community Services Australia, Patrick McClure, said that as the Deputy Coroner had made a recommendation to the Department, it was appropriate to await their assessment before making any comment on the matter.  

Tags: acsa, aged-and-community-services-australia, aged-care, ageing, baptist-community-services, bcs, bennelong-house, carmel-forbes, coroner, dead, death, deputy-coroner, deputy-state-coroner, die, died, iris-conyngham, nursing-home, patrick-mcclure, ross-low, shalom-centre,

4 thoughts on “NSW Deputy Coroner: nursing homes must review deaths

  1. It is sad to read that the RN on duty at the time was considered a poor witness considering the RN is in charge of the residents admission and asessment. It would suggest that the RN (as most do in aged care)needs more and better training in the specialised skills needed for Geriatric care. I for one would like to know if a professional diary was kept by the nurse and if there has been a process of reflective practice taken with some support for the nurse from the organisation. Organisations need to be reminded of the barriers they place in front of nurses to achieve quality outcomes.

  2. It should be incumbent on our Public Servants to be a bit better informed before making sweeping statements and calling for widespread changes as a result of one incident from one Provider. As a Provider who continues to provide a high standard of care for Residents and has robust systems in place to ensure continuity of care including all aspects of death and dying, this is an uncalled for and harsh judgement and responding to this will add another layer on an already overburdened system. The unexpected death of any Resident is regretable, however the Provider involved should be called to account, not the whole of the aged care industry.

  3. Why is all the blame related to the nursing staff and NUM’S, not to management when their is not a clear cut ratio across the board between nursing ratio’s per Residents or Patients,this also needs to be addressed so staff have time to put all procedures into place.

  4. Any death is regretable and should be investigated -however any person who has a relationship with aged care facilities should (if they investigated adequately) understand that the staffing ratios within facilities is abysmal when compared with acute facilities – and this needs to be taken into account. If such criticisms are to leveled at Aged Care then there must be formal recommendation to introduce appropriate staffing levels.

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