Coroner's Finding: Rouse, Wayne Victor
Deceased
Wayne Victor Rouse
Demographics
68y, male
Date of death
2023-06-14
Finding date
2023-10-10
Cause of death
Sudden cardiac death due to congestive cardiac failure and chronic obstructive pulmonary disease with underlying coronary atherosclerosis and cardiomegaly
AI-generated summary
Wayne Victor Rouse, 68, died from sudden cardiac death at a residential aged care facility when CPR was not provided despite his active resuscitation order. Staff incorrectly believed he had a 'do not resuscitate' order due to documentation errors and communication failures. The nursing handover sheet contained incorrect information, and the goals of care plan was not readily accessible. While medical evidence suggests CPR would likely have been unsuccessful given his advanced cardiac disease, the failure to attempt resuscitation violated his expressed wishes. The facility has since implemented comprehensive changes including colour-coded resuscitation status signs, standardised document storage, and staff education. The coroner recommended reviewing staffing levels, as the single registered nurse and care worker were attending another resident when Mr Rouse collapsed.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Procedures
Contributing factors
- Documentation error in nursing handover sheet indicating 'not for resuscitation' when actual goals of care were for resuscitation
- Goals of care plan not readily accessible to staff
- Inadequate communication of resident's resuscitation wishes to staff
- Staffing shortage resulting in delay in response to call bell
- Only one registered nurse and one care worker rostered
- Confusion between resuscitation and non-resuscitation orders
Coroner's recommendations
- The RACF should review its staffing levels and ensure it has adequate staff rostered on to enable more than one resident to be assisted at the one time
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