Inquest Into The Manner And Cause Of Death Of Jamie Vincent Johnson

Contributing factors

• failure of carer to supervise Jamie in shower as required by Individual Plan
• casual worker not familiar with Individual Plan requirements
• inadequate communication between hospital and disability services staff following first seizure in June 2000
• poor information transfer to casual staff
• privacy and confidentiality policies preventing circulation of critical safety information
• management failure to respond appropriately to June seizure implications
• lack of continuity in ASM supervision at the residence
• competing demands on carer managing two residents with challenging behaviours
• insufficient training of casual workers
• lack of protocol between hospital and community disability provider

Coroner's recommendations

1. Implement a procedure at all Disability Services houses requiring all staff, especially casuals, to read the individual plan and relevant materials before commencing a shift; ensure any new materials since previous shift are read
2. Further consider communication between house carers (casual and permanent) and Senior Management of Disability Services to ensure decisions are understood by all and made with full knowledge of facts
3. Institute proceedings against Debra Burnett for dismissal from the ACT Government Public Service if she remains employed
4. Set up a dedicated group of trained police officers to assist with coronial investigations of deaths in the Territory, particularly where the deceased was subject to care by Government instrumentalities
5. Conduct a thorough ongoing review of privacy and confidentiality policies within Disability Services; these policies had become counterproductive in preventing proper staff communication about resident safety; incident reports must be available as information tools for all carers
6. Develop a protocol between Disability Services and all ACT Hospitals requiring information about persons in care to be provided directly to their carers
7. Develop procedures ensuring casual staff are kept informed of all issues involving resident care; provide funding for casuals to attend meetings and training
8. Review record keeping and file systems at houses and regional offices to reduce multiple files; maintain one comprehensive file per individual containing all relevant material; coordinate file locations with clear procedures for maintaining relevant documentation at the residence while the main file is kept at regional office
9. Amend section 58 of the Coroners Act to allow judicial discretion for the coroner to continue a hearing notwithstanding notices have been issued under s58(1), where issues do not directly bear on manner and cause of death