Coroner's Finding: Mackozdi, Janet Lois

Contributing factors

• inadequate shelter in uninsulated shipping container with large gaps and minimal heating
• severe malnutrition and weight loss (28% loss in final 12 months)
• advanced Alzheimer's dementia and delirium
• inability to care for self or remove self from cold environment
• lack of medical oversight and medication monitoring
• refusal of appropriate residential aged care despite medical recommendations
• disengagement from general practitioner care
• lack of community health services
• inability to communicate distress or seek help

Coroner's recommendations

1. Tasmanian government to undertake review of legislation to determine whether current legislation effectively prevents or responds to abuse, neglect or exploitation of older persons, and commence legislative reform if needed
2. Develop renewed Elder Abuse Prevention Action Plan including: strategy to ascertain prevalence of elder abuse; strategy for responding to and preventing elder abuse; and establishment of steering committee for implementation
3. Undertake analysis of applicability of recommendations contained in ALRC Report 131 (Elder Abuse - A National Legal Response) and NSW Legislative Council inquiry recommendations
4. Give consideration to establishment of independent body with specific responsibility for elder abuse including investigating complaints, researching ill-treatment of older people, developing community education programs, and overseeing cases at risk of elder abuse
5. Alternatively, enhance powers and appropriately resource the Office of the Public Guardian to perform elder abuse protection functions
6. Resource and utilise Preventing Elder Abuse Tasmania (PEAT) as appropriately qualified advisory group for law reform and prevention strategies