Non-inquest findings into the death of MH, an aged care resident

Contributing factors

• Inadequate pressure injury risk assessment using validated tools
• Inappropriate pressure injury prevention strategies
• Use of donut cushion which creates pressure rather than relieves it
• Inconsistent implementation of repositioning protocols
• Poor documentation practices in wound assessment and care planning
• Failure to recognise and respond to rapid deterioration of wound
• Inadequate wound review frequency given severity
• Failure to assess and manage wound-related pain
• Lack of clinical skills and knowledge regarding pressure injury management
• Inadequate clinical oversight of care implementation
• Poor communication and coordination between RACF and general practitioner
• Failure to recognise behavioural changes as indicators of unmet care needs in person with dementia
• Delayed escalation for medical review
• Osteomyelitis developing in context of unrelieved pressure and contaminated wound

Coroner's recommendations

1. Implementation of evidence-based pressure injury risk assessment tools such as Braden or Waterlow scales
2. Enhanced education and training for registered nursing staff regarding pressure injury prevention, staging, and management
3. Development of comprehensive care planning documentation that specifies frequency of repositioning and other pressure relief strategies
4. Implementation of consistent wound assessment protocols including regular photography and staging
5. Assessment and management protocols for wound-related pain in aged care residents
6. Recognition and response to behavioural changes as potential indicators of unmet care needs in people with dementia
7. Improved clinical oversight and incident reporting systems for pressure injuries
8. Enhanced communication and coordination between aged care facilities and general practitioners
9. Consideration of escalation to higher levels of care when deterioration is observed