Non-inquest findings into the death of Malcolm Daniel Moriarty

Contributing factors

• Unlocked medication trolley left accessible to resident
• Failure to secure medications as per facility policy
• Complacency regarding standard medication storage practices
• Inadequate search of resident's room and person after initial medication ingestion discovered
• Failure to follow up with GP after initial incident
• Delayed escalation to urgent medical assessment after additional medications found
• Propped-open swipe access doors to medication room
• Systemic non-compliance with aged care quality standards
• Inadequate supervision of medication practices

Coroner's recommendations

1. Medication trolleys must always be locked when unattended, never propped open or left accessible
2. Electronic swipe access to medication rooms should remain secured and not held open
3. All staff require training and regular refresher education on medication security and administration protocols
4. When a resident is found to have ingested non-prescribed medication, thorough searches of the resident's room and person should be conducted immediately
5. Any incident involving non-prescribed medication ingestion warrants urgent medical assessment and hospital transfer for evaluation
6. Regular audits and random compliance checks of medication storage and administration practices should be maintained
7. Systematic reviews of medication administration rounds should ensure medications are dispensed from locked trolleys and staff remain with residents until medication is seen to be swallowed
8. Facilities should maintain awareness of and address complacency in standard medication security practices