Coroner's Finding: D Angelo, Adelina

Contributing factors

• Failure to recognise mild hypernatraemia in June 2020 blood tests as marker of dehydration risk
• Failure to provide explicit instructions to nursing staff to monitor fluid intake following abnormal blood results
• Inadequate quantification of fluid intake in three-day food and fluid chart in July 2020
• Removal of fluid calculation prompts from care review documentation system
• Cessation of daily fluid intake measurement after July 2020
• Widespread misunderstanding that dehydration in elderly can be detected by clinical signs alone
• Locum doctor's failure to consider dehydration despite lethargy and poor oral intake
• Locum doctor's unsound differential diagnosis of stroke based on asymmetric tone
• Locum doctor's failure to verify patient's documented advance care wishes
• Locum doctor's failure to contact family regarding suspected serious condition
• Delay in hospital transfer by 18 hours
• Dementia affecting thirst sensation and ability to seek food and fluids independently
• Use of diuretic medications increasing dehydration risk
• Insufficient staffing and monitoring resources in aged care facility

Coroner's recommendations

1. Forward a copy of the finding to the Commonwealth Minister for Health, Disability and Ageing with a request to consider the concerning prevalence of dehydration in older persons living within aged care facilities, particularly those with risk factors such as dementia, chronic renal disease and use of diuretic medications
2. The Medical Research Future Fund should consider providing a grant opportunity to enable development of an evidence-based dehydration intervention pathway for older Australians living within aged care facilities
3. Forward a copy of the finding to the Commonwealth Aged Care Quality and Safety Commissioner and the Commonwealth Inspector-General of Aged Care with a request to consider implementation of the recommendations directed toward them
4. Amend the Strengthened Aged Care Quality Standards (potentially within standard 5.5.5) to require: measuring daily fluid intake of residents who are clinically dehydrated; measuring daily fluid intake of residents assessed as at risk of dehydration including all residents with dementia and those on diuretic medications; recognising inadequate fluid intake; responding to inadequate fluid intake
5. Amend the poster 'Preventing Urinary Tract Infections - Recognise Dehydration' published by the Aged Care Quality and Safety Commission to reflect that caution must be exercised in identifying dehydration in older persons based on observable signs as it may only be reliably identified by blood test
6. The Aged Care Quality and Safety Commissioner should provide educational resources to aged care providers regarding the prevalence of dehydration in older persons and the unreliability of traditional assessment methods in detecting dehydration
7. The Nursing and Midwifery Board of Australia should ensure nurses working in aged care receive specialised training on maintaining hydration in older persons, including: recommended daily minimum fluid intake; unreliability of traditional assessment methods; medical conditions or treatments increasing dehydration risk; strategies to encourage adequate fluid intake
8. The Royal Australasian College of General Practitioners should provide urgent further education to redress widespread use of unreliable assessment methods to detect dehydration in older persons by General Practitioners
9. General Practitioners working within aged care should provide advice to aged care facilities regarding hydration needs of their patients, including recommended daily minimum fluid intake and steps to be taken in event of inadequate fluid intake