Finding into death of Caterina Montalto

Contributing factors

• Inadequate supervision of resident with high falls risk and wandering behaviour
• Hazardous courtyard environment (tripping hazards including garden light bollards)
• Failure to implement physiotherapy recommendations for assisted walking
• Insufficient staffing levels to provide constant assistance
• Unattended access to courtyard with water feature for dementia residents
• Failure to report death to coroner as required
• Misleading information provided to GP about circumstances of death
• Absence of incident reporting by nursing staff
• Poor organizational culture and governance regarding safety reporting
• Prolonged time unattended (approximately 51 minutes from fall to discovery)

Coroner's recommendations

1. Arcare should review the Verification of Death Assessment form to include a tick box regarding requirement to report deaths associated with or possibly associated with a fall to the coroner.
2. Include in the Examples of reportable deaths to the coroner in the Arcare Employee Information Guide a death that was or may have been associated with a fall.
3. Undertake regular audits (no less than 6 monthly) of the circumstances of death of a sample of residents who have died and not identified as a reportable death, until Arcare is satisfied the new system is effective in capturing all reportable deaths.
4. Due to the proximity of the stone-laden fountain to the courtyard path, remove the fountain from this location as well as any other similarly positioned and dimensioned objects in the courtyard that would be a potential risk to residents of Jasmine Unit.
5. The Australian Government Department of Health and Ageing Aged Care Complaints Scheme undertake an investigation into the actions of Arcare regarding the cover-up of Mrs Montalto's death circumstances and whether referral to appropriate agencies to review professional registrations should be expected within the Aged Care Act 1997.