Inquest into the death of William John Torrens

Contributing factors

• failure to obtain specialist dementia diagnosis prior to admission
• failure to recognise cognitive impairment on GP assessment despite documented short-term memory loss and wandering behaviour
• absence of system for regular headcounts at mealtimes or handover
• no sign-out or sign-in process for residents
• failure to monitor resident absence and determine they were missing until 6 hours had passed
• delayed police notification (7 hours after disappearance)
• inadequate supervision of resident known to be wandering
• removal of monitoring (hourly sight chart) based on assumption resident was no longer at risk
• lack of engagement with Dementia Behaviour Management Advisory Service
• high river levels and difficult conditions affecting search

Coroner's recommendations

1. System improvements implemented at Fairview after the incident, though these are noted as historical rather than recommendations from this inquest, given the facility's change of ownership and dissolution
2. Implementation of meal tick sheet to ensure no residents miss meals without explanation
3. Improvements in security and risk assessment of residents
4. Earlier engagement with Dementia Behaviour Management Advisory Service for residents with dementia and wandering behaviour