Inquest into the death of Kelvin Forrest

Contributing factors

• inadequate supervision of patient with wandering behaviour due to dementia
• failure to implement continuous 1:1 specialised nursing supervision despite documented risk
• unlocked veranda door left accessible to accommodate another patient's behavioural needs
• lack of medical review after significant incident (found on road)
• failure to adequately communicate wandering risks at shift handovers
• characterisation of admission as 'social' rather than medical, reducing clinical vigilance
• competing patient needs not systematically managed on ward
• insufficient understanding of home-seeking behaviour in dementia
• delays in NDIS funding approval extending hospital stay
• poor liaison between hospital and disability support services
• limited awareness and use of Health Disability Inclusion Manager role

Coroner's recommendations

1. NNSWLHD to implement an admission process whereby explicit consideration is given and recorded as to whether the patient experiences a disability and/or is an NDIS participant, with explicit consideration of barriers to care and necessary service adjustments, including consideration of referral to the Health Disability Inclusion Manager
2. NNSWLHD to consider implementation and/or adaptation of the Revised Algase Wandering Scale (RAWS) – Long-Term Care Version for patients presenting with a history of wandering or who engage in wandering whilst admitted
3. All staff engaged in casework, Team and Support Coordinator roles and managerial roles at United Disability (ACCnet21) to complete mandatory training in consultation with NDIA representatives on: (a) requirements under NDIS Act regarding approval, review and increasing funding; (b) the 'Determining Need - Identifying Suitable Housing Solutions' guideline; and (c) evidence required for completion of all forms submitted to NDIA including Plan Review Report, Change of Circumstances Form, Review of Reviewable Decision form, and Support Coordination End of Service Report