Coroner's Finding: Westcott, Barbara
Deceased
Barbara Westcott
Demographics
84y, female
Date of death
2012-03-31
Finding date
2016-09-01
Cause of death
Positional asphyxia due to head and neck entrapment between mattress and bed pole
AI-generated summary
Barbara Westcott, aged 84, died of positional asphyxia on 31 March 2012 when her head and neck became trapped between her mattress and a bed pole at Vaucluse Gardens aged care facility in Hobart, Tasmania. The bed pole, installed in 2009, should have been removed following a June 2010 coronial alert from South Australia documenting similar entrapment deaths. Despite developing comprehensive policies requiring risk assessment and removal of bed poles, the facility failed to identify and remove Mrs Westcott's device over 21 months. Staff shortages prevented the promised half-hourly safety checks, delaying any possible discovery. Systemic failures at multiple levels—management, nursing oversight, care planning reviews, and compliance audits—allowed a known dangerous device to remain on her bed. The coroner found this preventable death resulted from collective failure to implement established safety procedures and recommended ceasing use of KA524 bed poles, improving staffing levels and first aid training.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Contributing factors
- Bed pole remained on bed without proper risk assessment despite June 2010 alert about entrapment dangers
- Failure to implement risk assessment and removal procedures post-alert
- Inadequate staffing levels preventing provision of promised half-hourly checks
- Multiple failures in systems and processes to detect and remove bed pole across 21 months
- Staff awareness gaps regarding bed pole alert and associated policies
- Complex facility layout with single Extended Care Assistant covering four floors on night shift
- Patient immobility and cognitive impairment contradicting appropriateness of bed pole
Coroner's recommendations
- Aged care services and approved providers immediately cease use of bed poles of the model KA524 or similar style in aged care facilities
- Department of Health and Ageing promptly draws these findings and recommendations to the attention of all Australian aged care services and approved providers
- The facility undertakes a program to provide all Extended Care Assistants with appropriate and current first aid qualifications
- The facility rosters a minimum of two Extended Care Assistants in the Manor during the night shift
- The facility reviews its current policy implementation processes to ensure all staff are notified promptly of alerts, policies and alterations to policies concerning resident care and safety, with regular updates and reminders
- The facility reviews its systems and processes for maintaining records, including resident files, to ensure they are retained in a complete, ordered and accessible manner for the required period of time as provided by archiving legislation
- The facility develops a consistent and rigorous process for internally investigating and responding to significant incidents
Full text
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