Finding into death of Norma Alice Bensley

Contributing factors

• Medication error—administration of another resident's medications
• Inadequate supervision and support of newly qualified nurse
• Understaffing (rostering error)
• Large medication round (49 residents for single nurse)
• Lack of uninterrupted support during medication administration
• Delayed recognition of severity of medication error
• Failure to direct immediate hospital transfer
• Pre-existing ischaemic heart disease with severe coronary stenosis
• System failure in critical incident management

Coroner's recommendations

1. Commonwealth Department of Health's Office of Aged Care and Quality Compliance liaise with Southern Cross Care regarding learnings from this death and communicate said learnings to all aged care facilities throughout Victoria to reduce risk of similar deaths
2. Commonwealth Department of Health's Office of Aged Care and Quality Compliance undertake education and awareness raising activities to all clinicians working in the aged care sector, supporting the Poisons Information Service be routinely contacted when a medication error occurs
3. Roles and responsibilities of senior staff should be reviewed and processes involved in line management in emergency response situations be clearly stipulated, with Centre Manager holding ultimate responsibility when incidents occur