Inquest into the death of Rachel Martin
Deceased
Rachel Anne Martin
Demographics
28y, female
Date of death
2017-11-05
Finding date
2022-10-21
Cause of death
Multiple injuries sustained when struck by a truck on the M1 Pacific Motorway
AI-generated summary
Rachel Martin, a 28-year-old SNAP support worker and pregnant woman, died attempting to prevent harm to a high-needs child (Riley) during respite care transport. While driving Riley home on the M1 Motorway, Riley exited the vehicle and ran across traffic; Rachel followed attempting to catch him and both were struck by a truck. Critical failures included: inadequate referral information from DCJ about Riley's known transport risks (autism, propensity to remove restraints, requiring two carers), insufficient staff training and briefing, excessive fatigue (Rachel worked 27.5 continuous hours including overnight care alone with a high-needs child), inadequate carer ratios (1:1 instead of 2:1 as assessed for other respite providers), and rushed ad hoc placement approval bypassing normal safety procedures. The coroner found the death preventable and recommended policy changes to SNAP regarding rostering limits, transport protocols, staff training, and escalation processes.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Contributing factors
- Inadequate information transfer from DCJ to SNAP regarding Riley's known transport risks and behavioral support needs
- Failure to provide Riley with two carers as assessed necessary for his level of support
- Excessive and unsafe work hours for Rachel (27.5 continuous hours including overnight solo care of high-needs child)
- Insufficient staff training and briefing on Riley's specific needs and behavioral risks
- Inadequate sleep during overnight shift (required to sleep in same room as client to monitor)
- Rushed and ad hoc respite placement approval process bypassing normal safety procedures
- SNAP's failure to obtain updated behavioral support plan and risk assessment information
- SNAP's failure to request critical information despite identifying gaps
- Unsafe transport arrangement: single carer with high-needs child known to escape restraints
- Vehicle restrained child (Riley) using only standard Houdini strap, not secure harness recommended
- No support person or emergency contact arrangements for transport
- Rachel's minimal experience with Riley (first care episode)
- Rachel's fatigue and exhaustion from excessive work hours
Coroner's recommendations
- SNAP to review and develop staffing policy preventing any employee being rostered beyond a double shift (two 8-hour shifts or sleep-over shift plus 8-hour shift) without 10-hour break between shifts
- SNAP to engage independent third-party advisor to: deliver session to senior executives on risk implications of staffing levels; assess appropriateness of new rostering policy; deliver workshop to staff and management on associated risks
- SNAP to develop policy for staff to elevate concerns regarding staffing challenges through process independent of executives and managers
- SNAP to ensure PART (Predict Assess Response Training) or similar training becomes cyclic refresher training program for all staff and new employees
- SNAP to update transport policy to: provide driver with details of available support person who can attend vehicle during transport; prohibit driver from exiting vehicle alone on motorways/highways save for emergencies; prohibit opening vehicle doors on motorways/highways alone save emergencies; require emergency services or support person be contacted to safely access child when needed
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