Coroner's Finding: Martha McKee
Deceased
Martha McKee
Demographics
91y, female
Date of death
2010-07-28
Finding date
2011-08-26
Cause of death
asphyxiation due to neck entrapment on KA524 bedpole following fall from bed
AI-generated summary
Martha McKee, 91, died from asphyxiation when her neck became entrapped on a KA524 bedpole after falling from bed at Mid Richmond Aged Care on 28 July 2010. Multiple systemic failures contributed: one night carer was responsible for 45 residents including 20 high-care patients; staff failed to check vital signs when discovering her at 5am despite policy and training requirements, missing a potential resuscitation window; and the facility inadequately risk-assessed the bedpole despite a June 2010 Department of Health warning following a similar death. Facility management incorrectly assumed immobile residents were safe despite Mrs McKee's demonstrated ability to move. The coroner found Baptist Community Services breached Aged Care Act responsibilities and recommended immediate cessation of KA524 bedpole use across all facilities.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Contributing factors
- inadequate staffing on night shift (one carer for 45 residents, approximately 20 high-care)
- failure to check for signs of life when discovered at 5am despite policy requirements
- inadequate risk assessment of bedpole safety
- continued use of KA524 bedpole despite Department of Health bulletin and South Australian coronal recommendations
- failure to implement emergency protocols in practice
- facility incorrectly assumed immobility precluded fall risk
Coroner's recommendations
- Recommend that Federal and State Ministers advise the Department of Health and Ageing of the findings and recommendations of this inquest
- Recommend that all approved providers discontinue use of the KA524 bedpole in aged care facilities due to unacceptable risk
- Aged care organisations should continuously review staffing requirements to ensure resident and staff safety, not limited to legislative compliance
- Staff training should emphasise critical policies including checking for signs of life, potentially through simulated exercises during staff development rather than induction paperwork alone
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