Simons, Kathleen

Contributing factors

• Inadequate wound assessment and documentation by aged care nursing staff
• Failure to escalate wounds to hospital despite signs of deterioration with exposed tendons
• Inadequate GP review and follow-up; poor documentation of GP assessments
• Lack of wound swabs or microbiological investigation despite clinical deterioration
• Engagement of unqualified wound care consultant without verification of credentials
• Inadequate communication with family about severity of wound deterioration
• Lack of process for credentialing external wound care consultants
• Reliance on nursing staff to request further GP review rather than proactive follow-up by GP
• Doctor-nurse power dynamic leading to deference to physician opinion without questioning

Coroner's recommendations

1. Regis to establish and maintain a register of wound care specialists with appropriate credentials and qualifications
2. Ensure all external wound consultants are suitably accredited and clinically trained
3. Implement mandatory wound management training for nursing staff
4. Require weekly photographic documentation and measurements of chronic wounds in accordance with facility policy
5. Establish clearer referral pathways for complex wounds not responding to conservative treatment
6. Ensure nursing staff understand they can refer residents to hospital if concerned about adequacy of GP care
7. Implement processes to ensure regular and timely communication with family about significant changes in resident health status, particularly regarding wound deterioration
8. GP attending aged care facilities should have proactive follow-up systems for chronic wounds rather than relying solely on staff to request further review
9. Document clinical reasoning for treatment decisions in medical notes, particularly when conservative management is chosen for serious wounds