AN INQUEST INTO THE DEATH OFCHARLES ROWAN McCULLOCH

Contributing factors

• Inadequate supervision of newly admitted resident Mr McCulloch
• Failure to check welfare of other residents in Room 43 following violent altercation between VH and Mr Durr
• Unsupervised return of VH to his room after incident without assessment or staff accompaniment
• Mr McCulloch left unattended for 53 minutes (7:05am-7:58am) on morning of admission
• Failure to check vital signs to confirm death when Mr McCulloch was discovered
• Inappropriate handling of deceased: no staff member remained with body, body was interfered with (pillow placed over face, napkins in airway), room not secured
• Significant delay in contacting Police (55 minutes)
• Direction from management not to call Police immediately; instead instructing staff to contact doctor first
• Chaotic response upon discovery of deceased with multiple staff entering room unnecessarily
• Inadequate protocols for suspicious deaths and response to incidents
• Medication compliance issues: VH did not receive prescribed Risperidone consistently
• Falsification of surveillance charts by night staff
• Insufficient training and protocols for dealing with dementia residents with aggressive behaviour
• Limited information transfer from night shift regarding VH's known territoriality

Coroner's recommendations

1. Policy recommended by Senior Constable Thexton relating to suspicious deaths and matters to be referred to the Coroner should be adopted and implemented by Jindalee and all other aged care facilities in the ACT
2. Staffing requirements of aged care facilities be reviewed and a minimum staffing requirement be set for dementia specific units such as C Wing at Jindalee - minimum should match T-BASIS model: registered nurse on duty at all times with additional three staff until 9pm, then additional staff member until day shift commencement, plus nurse manager during day
3. Compulsory mandatory minimum training be implemented for staff employed in aged care facilities who care for residents diagnosed with dementia
4. To ensure safety of residents and staff, undertake review and implementation of policies and procedures including: behavioural management strategies for dementia residents with aggressive tendencies; mandatory reporting and recording of all incidents of violence; procedures for dealing with deceased residents; development of efficient record keeping system preferably electronic
5. To ensure safety of residents and staff, Jindalee and all aged care facilities undertake training or updating in Compliance with Elder Abuse reporting and maintenance of a register in accordance with Aged Care Act 1997 (Cth)
6. Jindalee undertake review of staff structure to ensure management fulfil requirement to supervise and monitor staff and ensure task compliance
7. Discretion reposing in management of aged care facilities to determine whether assault is 'reportable assault' under Aged Care Act 1997 (Cth) where resident has cognitive impairment should be removed - there should be requirement for mandatory reporting of all assaults in aged care facilities
8. All aged care facilities with dementia unit should be required to disclose to families of prospective residents prior to admission: the level of risk of violence for potential residents considering their particular circumstances; established protocols for protecting residents from witnessing and/or experiencing violent events; protocol for advising relatives of violent incidents as they occur so relatives can reassess circumstances from time to time