Inquest into the death of Marcia Clark

Contributing factors

• Prolonged neglect by carer
• Inadequate medical documentation and follow-up
• Failure to conduct home visit or in-home assessment despite known risk factors
• Carer (Nardia) was overwhelmed and struggling with own health
• Inadequate exploration of non-compliance with recommended treatment
• Delayed access to aged care assessment and support services
• Poorly controlled pressure ulcer over 7 months with only topical corticosteroid treatment
• Mother's mental illness (bipolar disorder) and refusal to allow strangers in home
• Lack of proactive screening for elder abuse or neglect
• Insufficient documentation of physical examination findings

Coroner's recommendations

1. Case study should be made available to Elder Abuse Helpline and Resource Unit and research groups at University of Sydney for educational and policy purposes
2. The need to establish specialised services (separate from NSW Police) with capacity to enter homes and investigate elder abuse and neglect concerns when less intrusive support has failed
3. Improvement to Aged Care Assessment Teams' access procedures, particularly addressing capacity consent barriers
4. Reduction of delays in Home Support Package commencement (currently averaging 9 months)
5. Healthcare professionals should maintain critical thinking about care arrangements for older people and recognise need for changing care over time
6. Family members, doctors and others should be curious about how carers are actually coping beyond outward appearance
7. Use of Elder Abuse Suspicion Index card and 'red flag' prompts in general practice for high-risk patients
8. Consideration of expansion of Elder Abuse Helpline case coordination trial programme