Inquest into the death of Hazel BROCKETT
Deceased
Hazel Brockett
Demographics
86y, female
Date of death
2016-07-23
Finding date
2020-03-03
Cause of death
complications of femoral, radial and ulnar fractures; antecedent cause Alzheimer's disease
AI-generated summary
86-year-old Hazel Brockett died from complications of fractures inflicted by a fellow dementia-affected resident in a locked Memory Support Unit (aged care dementia facility). Over months prior, the other resident demonstrated escalating physical and verbal aggression toward staff and residents. Multiple clinical failures prevented intervention: behaviours were inadequately documented and communicated to the GP; the assumption that pain caused aggression led to inappropriate opioid use; no formal case conference was held despite clear triggers; specialist referrals (DBMAS, geriatrician) were not made despite being indicated; and communication between care staff, management, and the GP broke down. Mrs Brockett, who became bedridden weeks before the incident, was not considered for transfer to safer accommodation. The coroner found systemic failures in coordination, documentation, behaviour assessment, and escalation procedures that could have triggered intervention.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Procedures
Contributing factors
- failure to escalate aggressive behaviour to senior management or specialist services
- inadequate communication between care facility, GP, and specialist services
- assumption that aggression was pain-related rather than considering alternative causes
- inappropriate use of opioid analgesia (Ordine) to treat agitation
- inadequate documentation and reporting of behavioural incidents
- lack of formal case conferencing despite escalating behaviours
- failure to follow up specialist referrals
- fellow resident with severe dementia and escalating aggressive behaviours not transferred to appropriate psychiatric care
- inadequate supervision of vulnerable resident in open dementia unit
- lack of coordination between multiple treating clinicians
Coroner's recommendations
- Review procedures for clinical briefing of visiting GPs to ensure chronological summaries of aggression incidents for dementia residents are provided
- Review Care Manual 'Managing Behaviours of Concern' to provide guidance on when formal case conferences should be held for problematic aggressive behaviours
- Place alerts on AutumnCare for outstanding GP referrals to ensure they are followed up
- Use behaviour charts on a continual basis for MSU residents exhibiting persistent aggressive behaviours with separate coding for physical aggression
- Formulate clear policy guidelines for when and how to notify treating GP of resident-to-resident and resident-to-staff aggression
- Take detailed history on admission identifying resident's likes/dislikes, pre-morbid personality, sensitivities, preferences to guide care planning
- Ensure behavioural interventions are individually tailored to each resident through Quick Reference Guides
- Provide ongoing training for care staff on responding to aggressive behaviours, identifying underlying causes, and documenting context and triggers
- Introduce written procedure and policy on when external clinical review and transfer may be required
- Consider installing CCTV in common areas of dementia unit to review unwitnessed incidents
- Amend Incident Form to include guidance on notifying treating doctor, additional referral options (DBMAS, geriatric review), and case conference recommendations
Full text
Related cases
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —