Coroner's Finding: ROLLBUSCH Graham

Contributing factors

• assault by another resident (Mr Palmer)
• inadequate medical supervision and review
• poor standard of record keeping
• failure to separate residents despite documented prior assaults between them
• continued administration of olanzapine without medical review
• extreme weight loss and malnutrition not adequately managed
• lack of notification to Public Advocate of assaults and deterioration
• failure to consider transfer despite clear clinical indicators
• staff lacking knowledge and skills in dementia management
• poor clinical leadership and supervision
• inadequate nursing documentation

Coroner's recommendations

1. Adopt a register of resident to resident aggression in the aged care sector supported by mandatory reporting of such incidents, applying regardless of residents' cognitive status
2. Minister for Health to raise with counterparts in other States and Territories the proposition that such registers should be duplicated across Australia, or preferably, adoption of a National register at the Commonwealth Government level
3. Forward this finding and that of John Arthur Burns to the Commonwealth Minister for Senior Australians and Aged Care for consideration in the context of proposed Royal Commission into Aged Care, particularly regarding management of relatively young men with dementia and sexual disinhibition