Inquest into the Death of Ruth McKay

Contributing factors

• undetected access to external courtyard
• exposure to cold weather and hypothermia
• head injury sustained under vehicle
• bed and room sensors not activated
• corridor doors unlocked and accessible from inside
• absence of electronic monitoring or alarms on corridor doors
• dementia and Alzheimer's disease increasing susceptibility to infection and aspiration
• inadequate facility safety systems relying entirely on staff compliance

Coroner's recommendations

1. Implementation of electronic monitoring systems (door alarms, room sensors) in aged care facilities housing dementia residents
2. Physical security measures such as magnetic door locks that automatically lock at night for corridors accessing external areas
3. Robust policies ensuring consistent activation of sensor mats in accordance with individual care plans
4. Strengthened regulatory oversight of aged care facilities through the Aged Care Quality and Safety Commission
5. Mandatory reporting of serious incidents including unexpected deaths in aged care facilities
6. Clear staff responsibilities and procedures for incident response and cooperation with investigations
7. Regular hazard identification and management reviews by senior staff
8. Enhanced dementia training for aged care staff
9. CCTV monitoring in high-risk areas