Inquest into the death of Raylene Dick, David Hardy and Karen Bading

Contributing factors

• Failure to conduct meaningful clinical risk assessment on admission to CNR
• Failure to identify and act on abnormal vital signs (hypotension 80/49) at intake
• Assumption that CDC had conducted clinical risk assessment when they had not
• Assumption that CNR would conduct clinical risk assessment when they did not
• Case management team included non-clinically trained staff making placement decisions
• Inadequate intake assessment processes at CNR
• Reliance on telephone checks rather than in-person assessment
• Lack of clear allocation of responsibility for risk assessment between CDC and CNR
• Recent significant hospitalization (October-November 2021) not adequately considered in placement decision
• Family concerns and observations not acted upon promptly
• Delay in escalation and transfer to RDH despite clinical deterioration

Coroner's recommendations

1. Review policies to ensure detailed assessment of a person's reliance on third parties before determining suitability for quarantine in facilities assuming independent living
2. Review policies to ensure carers approved to isolate with infected persons are recorded in travel documentation
3. Establish appropriate health screening process for quarantine with clear allocation of responsibility, ideally occurring before arrival at facility
4. Ensure health screening triages individuals by risk and elevated-risk cases are reviewed by medical officer before transfer recommendation
5. Ensure health screening staff ask whether person has had recent hospitalization
6. Develop pro forma records identifying relevant medical details for at-risk residents
7. Develop individualized care plans for higher-risk residents including in-person medical review shortly after admission and specifying frequency of in-person reviews
8. Ensure quarantine facility staff have access to screening records
9. Provide Between the Flags observation forms to visually indicate abnormal observations to inexperienced clinicians
10. Provide electronic devices (tablets) rather than paper forms for recording observations
11. Develop system to facilitate communication between vulnerable residents' families and facility welfare officers including liaison officer position