Inquest into the death of Margaret Winter

Contributing factors

• misclassification of falls risk as low rather than medium
• failure to implement appropriate fall prevention strategies
• failure to perform half-hourly neurological observations as prescribed
• significant nursing staffing deficiency
• too few nurses for patient numbers and acuity
• excessive use of agency and overtime staff
• poor nursing skills mix with too many enrolled nurses relative to registered nurses
• nursing staff from different areas unfamiliar with the ward
• barriers to requesting additional staff for shifts
• withdrawal of recruitment delegations in early 2006
• staffing numbers set below evidence-based requirements
• lack of evidence-based methodology for determining staffing levels

Coroner's recommendations

1. An appropriate nursing staffing methodology should be implemented which gives consideration to casemix, acuity and patient turnover. The use of staff working double shifts, agency or pool staff should only occur under exceptional circumstances (such as sick leave, increased acuity, specialling and increased bed numbers) rather than being used routinely to fill shifts in a roster.
2. If additional staff are needed (PCAs, nurse specials, extra nurses for overflow beds) then the Nursing Resource Coordinator should have delegated authority to make this decision. This delegation should be documented in a policy document that is widely available. Reasons for the request, and reasons for any refusal, must be provided and documented so decisions are transparent.
3. Nursing staff should be required to complete either the Observation Special or the Neurological Observation Chart but not both.
4. The quality and safety processes need to be dramatically improved. Senior staff with appropriate authority need to be given the power to conduct reviews and making recommendations, if appropriate, in relation to sentinel events, and there needs to be a commitment at the highest levels to using the reviews to improve practice.
5. There should be an audit of the current compliance with the falls policy and, if it demonstrates a lack of compliance, steps should be taken to ensure the policy is complied with.