Finding into death of Stephen William Summers

Contributing factors

• Inadequate transition planning from institutional to community residential care
• Lack of continuity of familiar carers during move
• Absence of pre-transfer assessment by new general practitioner
• Poor coordination between Banksia House staff and community health services
• Failure to maintain contact with previous care providers from Kew Cottages
• Lack of staff training in pressure sore identification and prevention
• Three to four month waitlist for allied health services
• Inadequate monitoring of progressive weight loss (13kg over 2 months)
• Unrealistic expectations of client participation in transition planning despite profound communication disability
• Different reporting systems at new facility without oversight of deterioration
• No blood tests or investigation for Staphylococcal infection despite clinical deterioration
• Failure to diagnose pre-patellar bursitis
• General practitioner reliance on Banksia House staff assessment without establishing relationship with client
• No incident investigation by Department of Human Services after transfer to hospital

Coroner's recommendations

1. The Department of Human Services provide direct care workers in Community Residential Units with education and experience in identifying, preventing or managing pressure sores in disability clients
2. The Department of Human Services create a pool of allied health service providers with experience in managing disability clients and ensure that they are available to direct care workers for consultation and review of referrals for equipment like air mattresses
3. The Department of Human Services undertake systematic reviews of the management and other factors contributing to the death of residential clients with severe disabilities
4. The Department of Human Services require direct care workers in Community Residential Units to verbally report to the House Manager any observations they make of deteriorating health of disability clients as well as writing their observations in the Communication Book and the client's record
5. The Department of Human Services arrange for appropriate provision of community medical and allied health services to clients with profound disabilities who are referred by their carers
6. The Department of Human Services routinely audit all the community services provided to clients with profound disabilities to ensure they remain relevant to the clients' changing specialist needs and available when they are required