Finding into death of Mark Anthony Theakston

Contributing factors

• possible fibromuscular dysplasia of artery in atrioventricular node region
• moderate fatty change in liver (steatosis)
• previous organised focal subdural haemorrhage in right frontal lobe
• inadequate review of health monitoring needs following fall incident
• oversight checks did not include breathing assessment

Coroner's recommendations

1. Every resident in supported accommodation requires a health plan with a Health Support Needs Summary that must be reviewed/updated following any change in health and support needs
2. The fall/seizure incident on 21 May 2008 should have been subject to a Category 2 incident report and should have resulted in review of Mr Theakston's health and support needs
3. One possible outcome of review given the fall and possible head injury may have been to change overnight monitoring from visual sighting only to checking for breathing
4. The Department of Human Services should consider strengthening procedures around incident reporting and consequent review of the Health Support Needs Summary, and/or re-emphasizing its importance to supervisors and managers of residential supported accommodation