Finding into death of Lena Divola

Contributing factors

• Inappropriate use of walker for transport (pushing seated patient)
• Failure to communicate medical advice from general practitioner to care staff
• Misattribution of medical symptoms (vomiting, inability to rise) to behavioural disorder
• Excessive reliance on behavioural management strategy ('no entry' directive) without clinical flexibility
• Inexperienced night shift staff with limited training
• Lack of escalation protocol when patient presentation changed
• Inadequate handover and communication between shift staff
• 30-hour delay in seeking medical assistance
• Use of anticoagulant medication (warfarin) masking normal clinical picture
• Remote supervision model limiting on-scene decision-making

Coroner's recommendations

1. Secretary of Department of Human Services to review management arrangements at Armadale House to ensure appropriate discretion in health decision-making is vested in senior on-duty care provider at the House rather than remote supervisor
2. All medical instructions provided by medical personnel to staff be incorporated into resident's file in manner easily accessible to care providers
3. Incoming staff be required to acknowledge receipt of medical information for each resident either on hard copy or on-line to ensure awareness of critical clinical advice