Finding into death of Joan Hendrickson
Deceased
Joan Hendrickson
Demographics
78y, female
Date of death
2006-05-09
Finding date
2010-09-08
Cause of death
Aspiration pneumonia, epistaxis, and trauma to the face
AI-generated summary
Joan Hendrickson, a 78-year-old with vascular dementia, was assaulted by a co-resident at an aged care facility in April 2006, sustaining facial trauma and epistaxis. She died from aspiration pneumonia 10 days later. The coroner identified that a co-resident, JL, exhibited escalating aggressive behaviours over six months prior to the incident. The facility and JL's general practitioner failed to coordinate risk assessments or refer JL to the Aged Psychiatry Assessment and Treatment Team (APATT) despite clear indicators. Had APATT been engaged earlier, appropriate management strategies or placement changes could potentially have prevented the assault. Key failures included inadequate communication between nursing staff and the GP, lack of systematic risk assessment, and procedural shortcomings in behaviour management. Post-incident reforms introduced team leadership, better documentation systems, and improved liaison with specialists. The coroner did not find the failure to refer APATT causative of death but emphasised that procedural improvements were essential to prevent similar incidents.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Vascular dementia
- Permanent pacemaker
- Hypertension
- Failure to refer aggressive co-resident to APATT prior to assault
- Lack of coordination between facility staff and general practitioner
- Inadequate risk assessment for behaviour management
- Communication breakdown between nursing staff and medical practitioners
- Escalating aggressive behaviours of co-resident JL not escalated to specialist services
Coroner's recommendations
- Implement a coordinated approach to escalating challenging behaviours with systematic risk assessment and documentation
- Establish a team leader role (RN1) to catalogue challenging behaviours, collate documentation, ensure the general practitioner is fully informed, and discuss specialist service engagement with the GP and nursing leadership
- Ensure seamless communication between facility staff and general practitioners regarding resident behaviour and psychiatric symptoms
- Familiarise aged care service providers with readily available information on APATT criteria and access procedures
- Create a risk assessment tool that catalogues incidents of challenging behaviour and aggression
- Develop protocols ensuring that when a resident's medical condition or behaviours place co-residents at risk, steps are undertaken to protect vulnerable residents
- Ensure families of co-residents are fully informed of incidents that pose risk
- Utilise specialist services including APATT, Geriatric Evaluation and Management (GEM) Unit, Dementia Behaviour Management Advisory Service (DBMAS), and Aged Care Assessment Service (ACAS) when residents exhibit problematic challenging behaviours
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