Finding into death of Paquita Goldberg

Contributing factors

• behavioural and psychological symptoms of dementia (BPSD)
• paranoia and delusions
• possible delirium
• escalating distress and fear on 7-8 February 2013
• disclosure of trauma (recalled sexual assault in concentration camp)
• chaotic and noisy ward environment where patient reported feeling unsafe
• refusal of medications
• new aggressive behaviours requiring intramuscular antipsychotic administration
• inadequate incident reporting and documentation
• observation frequency not increased despite significant behavioural and clinical changes
• lack of detailed records of overnight events 7-8 February 2013
• ward environment not appropriate for dementia patients

Coroner's recommendations

1. Improved guidelines regarding nursing observations in acute psychiatric units for older persons, including procedures for verifying patients are alive and safe when observed
2. Enhanced incident reporting procedures to ensure all incidents of aggression requiring physical restraint or intramuscular medication administration are formally reported
3. Staff education regarding behavioural escalation in dementia and BPSD patients as potentially indicating increased risk of harm
4. Training for staff in aged psychiatry regarding elevated suicide risk in Holocaust survivors and other trauma survivors
5. Review of appropriateness of acute psychiatric ward environments for patients with dementia and BPSD, including consideration of noise levels and safety
6. Clear guidelines distinguishing between violence and aggression and when escalation of observation frequency is warranted
7. Implementation of improved documentation procedures including continuation of sleep/behaviour charts and observation worksheets