Inquest into the death of Neville Clutton

Contributing factors

• failure to report early aggression (25 November 2016 staff assault) to GP or management
• inadequate documentation of aggressive incidents in Behaviour Identification and Interventions Chart
• poor communication between care staff and management (Manager Morillas unaware of incidents)
• failure to conduct timely case conference despite escalating behavioral incidents
• delayed DBMAS referral (not made until after fatal incident)
• ineffective sight charts recording only location, not behavioral demeanor or state of mind
• failure to separate incompatible roommates despite identifiable conflict and escalating aggression
• inadequate investigation of incidents of 18 and 24 January 2017 before fatal event of 28 January
• no documentation of GP contact regarding incidents; poor handoff communication with GP
• insufficient training of staff in dementia behavioral management
• privacy concerns inappropriately prioritized over resident safety in withholding information from family
• inappropriate exercise of discretion not to report incident to Department of Health
• incomplete care plans not recording incidents or management actions

Coroner's recommendations

1. Amend guideline CM 3.13 'Management of Acute Behavioural Disturbance/BPSD' to include shared room status as relevant environmental contributing factor
2. Amend CM 3.13 'Emergency Care' section to include moving resident to single room with one-to-one staffing as a non-pharmacological action
3. Add reference to severe behavioral disturbance guideline in CM 3.13 reference documents
4. Amend CM 3.13 'Reassessment' section to reflect further assessment contemplated by proposed actions
5. Amend CM 3.13 to include section reminding staff to report and record all internal assessments and steps taken for BPSD
6. Develop or amend policy providing guidance on disclosure of risk factors to next-of-kin of other residents at risk when one resident demonstrates aggression toward others
7. Keep record in resident's file of all written communication with GP and record all clinical communication with GP (phone, fax, email) in electronic progress notes
8. Develop and implement chronological summary of resident's BPSD-related acts of aggression (verbal and physical) for internal and external clinical review and case conferencing
9. Consider developing and implementing graph-based or pictorial representation of chronological aggression summary for use with narrative summary
10. Amend Behaviour Management Procedure guideline CM 3.02.6 to clarify when case conferences are required, with examples such as escalating ongoing behaviors or consecutive high-risk incidents
11. Implement mandatory reporting of all resident-to-resident aggression incidents to Aged Care Quality and Safety Commission