Inquest into the death of Beryl Joyce WATSON

Contributing factors

• Omission of clonazepam (Rivotril) from medication list due to GP documentation error
• Failure to recognize benzodiazepine withdrawal syndrome
• Inadequate fluid and nutritional intake during respite stay
• Poor pressure area and skin care management
• Delayed medical review and response to deterioration
• Suboptimal medication administration practices at admission
• Inadequate handover communication at discharge
• Insufficient familiarity of aged care staff with patient's complex needs

Coroner's recommendations

1. Implement comprehensive admission procedures to ensure all staff are aware of and required to follow individualized care plans for respite residents
2. Develop formal care plans for all short-stay residents using the same processes as permanent residents
3. Ensure structured handover procedures at admission and discharge with detailed communication to family carers about any deterioration
4. Implement robust medication reconciliation processes to prevent omissions and detect discrepancies between different medication lists
5. Establish clear protocols for urgent medical review when complex patients show signs of deterioration, particularly behavioral changes suggesting medication withdrawal
6. Ensure fluid balance charts are completed accurately and fluid intake targets are monitored actively
7. Implement protocols for specialist assessment of pressure areas and skin care in high-risk patients
8. Establish clear escalation pathways to medical officers for patients showing signs of clinical deterioration, including provision of medical cover for respite facilities
9. Improve communication between aged care facilities and general practitioners regarding patient condition changes
10. Forward findings report to the Office of Aged Care Quality and Compliance to review implementation of BUPA's new policies