Coroner's Finding: McDonald, Maureen June

Contributing factors

• Failure to implement wound management plan during 19-26 January 2022
• Failure to implement wound management plan during 29 January-6 February 2022
• Failure to create new wound chart in electronic system resulting in loss of automated alert system
• Failure to recognise deteriorating condition evidenced by confusion and weight loss
• Failure to adapt care plan to evolving clinical needs
• Delayed recognition of wound deterioration from stage two to stage four
• Inadequate staffing oversight during senior staff disruptions
• Failure to ensure pressure relief measures were implemented as recommended by general practitioner
• Reduced documentation and care records from 25 December 2021 onwards

Coroner's recommendations

1. All registered nursing staff be regularly assessed for competency in wound classification, wound management, and recognising and responding to a deteriorating resident, with education programs addressing identified skill gaps
2. Residents be assessed for care needs at entry to aged care facility, at regular intervals during residency, and at times of condition change, utilising standardised tools such as the Waterlow tool for pressure wound assessment
3. A workflow system be considered and implemented to provide clarity to staff regarding specific care needs of residents, requiring recording of attendance to those needs and creation of an alert if care needs are not attended to
4. Care managers undertake weekly review of all wound charts to ensure wound management is appropriate, no tasks have been missed, and education or training needs for nursing staff are identified and actioned