Finding into death of Rohan Grindrod

Contributing factors

• Moderate acquired brain injury from 2007 motor vehicle accident
• Poorly controlled epilepsy with frequent seizures
• Non-compliance with anticonvulsant medication
• Personal Emergency Response device (VitalCall) not reconnected at new address
• Failure of case management services to include VitalCall device in move planning
• Lack of coordination between TAC, State Trustees, and Vista regarding equipment transfer
• Inadequate warnings from VitalCall manufacturer regarding disconnection consequences
• No risk assessment performed during case management planning for move
• Deceased lived alone at new address with flatmate absent during critical period
• Cannabis use (recent, detected at autopsy)

Coroner's recommendations

1. VitalCall to contact all users with similar devices, clearly warning that disconnection from telephone or power may cause device failure and that technician transfer is required
2. VitalCall to provide warning stickers clearly stating devices are not to be disconnected and advising contacting VitalCall for transfer
3. VitalCall to update all user literature (guides and brochures) to include clear warnings about disconnection consequences and need for technician transfer
4. TAC to write to all users of VitalCall devices warning about dangers of disconnection and advising technician transfer is required
5. TAC to include or require risk assessment when providing case management services (internal or outsourced) for any task requiring case management
6. TAC to implement 'hot note' warning or flag on electronic systems if not already done to alert staff when client has Personal Emergency Response device
7. TAC, State Trustees, and Vista to conduct review ensuring all clients with lifesaving equipment are recorded on electronic systems so equipment is identified as risk requiring evaluation upon any change in circumstances such as change of address