Coroner's Finding: Norman, Colin

Contributing factors

• failure to provide scheduled disability support care
• absence of protocol for responding to client refusal of care
• failure to follow shift coverage procedure
• failure to confirm shift change with new support worker
• failure of administrative staff to act on handover note regarding shift confirmation
• support worker non-attendance without notification system
• tension in relationship between support worker and client
• inadequate systems to verify worker attendance at shifts
• shift change not communicated to client
• inappropriate Enterprise Agreement clause placing shift coverage responsibility on casual workers
• high-risk client left without assistance for extended period
• lack of welfare check when care was refused

Coroner's recommendations

1. HomeCare+ should renegotiate the Enterprise Agreement to amend clause 15.4 such that the responsibility for shift coverage rests with the administrative staff rather than casual workers
2. HomeCare+ should amend its Shift Coverage Procedure and Position Descriptions in accordance with the renegotiated Enterprise Agreement
3. HomeCare+ should develop a Client Refusal of Care Procedure and ensure that all staff receive appropriate training in relation to that procedure
4. HomeCare+ should continue to explore implementation of a system to enable attendance of support workers to be monitored such that HomeCare+ is notified in real time of any non-attendance enabling appropriate action