Finding into death of Claus J Neff

Contributing factors

• failure to implement documented wandering risk management procedures
• inadequate admission process and care planning
• failure to deploy personal alarm device despite identified wandering risk
• failure to establish sighting chart
• poor communication at handover meeting regarding wandering risk
• lack of supervision of RN Jean-Francois
• absence of senior management (facility manager and director of nursing) on admission day
• inadequate documentation of wandering risk in interim care plan
• lack of clear information provided to resident regarding permanent admission
• insufficient staff awareness of wandering risk prior to absconding

Coroner's recommendations

1. All staff at Cardinal Knox Village continue to undertake initial training in dementia policies before commencement of duty and undertake full retraining not less than once every 12 months
2. The interim care admission form be amended to include a mandatory dropdown field in reference to strategies to be adopted to protect the resident, with this box requiring completion with details of strategy adopted and implemented before the remainder of the form becomes active