Finding into death of Margaret Elizabeth Barton

Contributing factors

• Excessive Oxazepam dosing (15mg three times daily, later increased to include additional 'as required' doses totalling 90mg over two days)
• Failure of Dr C. to follow up after significantly increasing Oxazepam dose
• Inadequate handover of information between RACFs regarding medication changes, falls, and care requirements
• Multiple GPs involved in care without continuity
• Dr O. unaware of recent Oxazepam dose reduction at discharge from CCM
• Inappropriate transcription and continued use of 'as required' Oxazepam order from CCM at MPH
• Poor communication between healthcare practitioners
• Delay in medical review at CCM for escalating behavioural issues (4 weeks into admission)
• Delayed referral to Aged Persons Mental Health Team (APMHT) and slow response
• Failure to radiologically investigate rib and pelvic fractures despite multiple documented falls
• Unidentified oral candidiasis contributing to poor oral intake
• Citalopram substituted for Escitalopram (medication transcription error) at different dose
• No formal falls risk assessment performed at CCM admission
• Inadequate neurological observations following unwitnessed falls at CCM
• Environmental and facility changes causing additional distress

Coroner's recommendations

1. CCM revise 'Management of a resident after a fall' policy to include greater clarity regarding nursing staff requirements for unwitnessed falls management
2. CCM provide internal education to staff on adequate post-fall management, including proper neurological observations performed half-hourly for at least four hours
3. CCM conduct internal review of documentation systems to ensure impending transfer location is readily accessible and documented
4. MPH amend policy to require written care plan or health summary for every resident admitted from another healthcare service, or document reasons if unavailable, and ensure verbal handover is sought
5. MPH provide internal education to all staff administering medications emphasizing professional judgement regarding appropriateness of medication orders, with particular focus on high-risk medications (insulins, narcotics, sedatives, anticoagulants)
6. Australian Aged Care Quality Agency (AACQA) review adequacy of clinical governance of medication administration at Park Hill Gardens RACF and at MPH, and adequacy of communication between RACFs
7. Australian Health Practitioner Regulation Agency (AHPRA) review appropriateness of medication administration at MPH and prescribing practices by Dr C.
8. Royal Australian College of General Practitioners (RACGP) use this case as educational tool for members on complexity of dementia care, importance of early escalation to specialist services, adequate inter-service communication, and appropriate prescribing with follow-up