Coroner's Finding: CECERE Rolando
Deceased
Rolando Cecere
Demographics
71y, male
Date of death
2006-01-23
Finding date
2008-11-06
Cause of death
Positional asphyxia
AI-generated summary
A 71-year-old man with severe dementia died from positional asphyxia when his neck became wedged in a gate at an aged care facility. He had demonstrated multiple escape attempts within days of admission, with staff documenting wandering behaviour and attempts to climb fences. The facility was inadequately secured with internal doors openable from inside and an external alarm disconnected. Despite clear warnings, no effective containment measures were implemented. The coroner found the death entirely avoidable and criticised inadequate security infrastructure, lack of clear checking policies, and poor documentation management. Key lessons include: properly securing aged care facilities for high-risk wanderers, implementing regular resident welfare checks, establishing clear policies for managing escape-risk residents, and maintaining accessible documentation of safety incidents.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Contributing factors
- Inadequate physical security of premises
- Disconnected alarm system on laundry door
- Internal doors openable from inside without keys
- Failure to recognize escape risk despite clear evidence
- Inadequate supervision protocols
- 15-minute observation intervals not practically implemented
- Lack of clear policies for managing wandering residents
- Poor incident report management and documentation
Coroner's recommendations
- Commonwealth Department of Health and Ageing and Aged Care Standards and Accreditation Agency to conduct thorough review of Saint Hilarion Aged Care facility at Lockleys
- Assess whether the facility is properly equipped to care for patients with dementia
- Review the facility's admission practices to ensure inappropriate admissions are not made
- Evaluate whether the facility has sufficient nursing and caring staff to provide appropriate standard of care
- Assess adequacy of record keeping practices, particularly in relation to incident reports
- Evaluate whether the facility provides a safe environment to residents
- Review facility's policies, practices and procedures for dealing with residents who wander
Full text
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