Inquest into the death of Barbara Francis

Contributing factors

• understaffing in dementia unit on day of incident
• absence of lifestyle staff member despite management directive
• inadequate orientation and induction of external community support worker
• lack of handover to inexperienced agency nurse
• disruption of Mr A's routine leading to behavioural escalation and aggression
• failure to ensure resident was wearing prescribed hip protectors due to laundry failures
• inadequate supervision and escalation protocols following first assault
• delay in ambulance dispatch (1.5 hours)
• management failure to implement existing staffing directives
• lack of training and familiarity of agency staff with residents and policies

Coroner's recommendations

1. Formalize a 000 emergency response policy requiring that the call back number provided is the mobile number of the Care Coordinator and that follow-up 000 calls are made no later than 30 minutes after the previous call (or sooner if warranted)
2. Amend the Dinah Guideline and roster to reflect that an extra PCA (or equivalent) must be present in Dinah during the one-hour lunch period to prevent staffing gaps
3. Ensure that all NDIS workers must have attended a site orientation and signed an Orientation Booklet before working with residents; amend guidelines to include mandatory client/resident-specific induction, not just site orientation
4. Provide all NDIS workers with an information folder containing care plan summaries and require them to advise the RN/EN before taking residents off-site
5. Implement a new handover process where off-going and on-coming care coordinators conduct joint ward visits with all staff going off and coming on shift to address staffing and clinical issues
6. Ensure agency staff are not deployed to Dinah except as an absolute last resort; roster Dinah with permanent Southern Cross Care employees only to ensure familiarity with policies, procedures, and resident-specific needs
7. Implement mandatory hip protector compliance monitoring; require families to provide three sets of hip protectors (one for wearing, one in laundry, one spare) with same-day laundering and return; make it mandatory that residents clinically assessed as requiring hip protectors wear them 24/7 or as per care plan, with nursing staff responsible for monitoring compliance
8. Formalize and improve the handover procedure to ambulance officers to ensure relevant information and documents are provided efficiently and address ongoing access issues to the locked dementia unit