Finding into death of Morgan Patrick MCCabe
Deceased
Morgan Patrick McCabe
Demographics
42y, male
Date of death
2014-04-27
Finding date
2018-11-13
Cause of death
Drowning
AI-generated summary
A 42-year-old man with Prader-Willi syndrome and obsessive-compulsive tendencies drowned at Phillip Island while on a supported holiday organised by Wesley Mission. The coroner found that planning for the four-client holiday with two carers was inadequate and driven by financial constraints rather than proper risk assessment. Patrick was used to a highly confined home environment but was placed in an unfenced house 25 metres from the beach, an environment that invited exploration by a curious and energetic man. No formal risk assessment regarding proximity to water was undertaken. The coroner identified failures in communication protocols for missing persons; when Patrick disappeared mid-afternoon, the carer (Xxx) delayed notifying police due to confusion about Wesley's internal approval processes. While Xxx made genuine efforts to locate Patrick, the combination of inadequate planning, insufficient staffing, poor risk analysis, and lack of clear emergency protocols contributed to a preventable death.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- Inadequate risk assessment and planning for holiday
- Failure to properly assess proximity of unfenced property to beach
- Insufficient staffing levels (2 carers for 4 clients with complex needs)
- No formal risk assessment documentation
- Lack of emergency management training for supervising carer
- Unclear internal protocols regarding police notification
- Financial constraints driving planning decisions over safety considerations
- Inadequate briefing on duty of care during holiday
- Environmental mismatch - restrictive home versus open holiday setting
- Delay in notifying police of missing person
Coroner's recommendations
- Wesley Mission should not plan holidays without proper funding being secured in advance
- Prior examination of proposed holiday homes and surrounding environment by qualified Wesley representatives experienced in disability risk assessment should be mandatory
- Holiday homes should preferably be fenced properties when taking clients with intellectual disability
- Clear, written emergency management protocols should be provided to staff before holiday departure
- Staff should be explicitly instructed to use their own judgment to call police and emergency services if a person in their care is missing or endangered, without requiring prior manager approval
- Proper staffing ratios should be established based on client needs rather than budget constraints
- Risk assessments should be undertaken and documented in writing for all holiday planning
- Missing persons procedures should be regularly reviewed with staff in team meetings
- Occupational health and safety checklists should be used for holiday venues including pathways, stairs, lighting and distance from water
- Staff should receive training in recognizing and managing obsessive compulsive disorder
- Wesley should consider requiring families to contribute to additional staffing costs if extra staff are needed
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