Finding into death of Steven Pimblett

Contributing factors

• Failure to escalate health concerns by home care worker to management
• Absence of clear escalation procedures at Banyule City Council
• Loss of contact by Department of Health and Human Services due to staff turnover
• Patient's resistance to outside assistance and medical care
• Inadequate assessment during general practitioner home visit
• Lack of individualized care coordination
• Insufficient staff training on escalation procedures
• No written notification of deteriorating health to disability services

Coroner's recommendations

1. Banyule City Council should develop and implement appropriate policies and procedures within an overarching home care policy for home care staff to support escalation of health and welfare concerns about a client and/or household member.
2. Banyule City Council should review its training for staff around policies and procedures in general, and specifically around implementation of new policies and procedures related to the home care policy.
3. Department of Health and Human Services should review its processes for maintaining a knowledge base about the needs of people requiring disability support services.