Finding into death of Dorothy Boyle

Contributing factors

• Room door not locked despite resident's request and facility policy
• Wandering behaviour of dementia-affected co-resident
• Resident-to-resident aggression incident
• Failure to execute systematic door-locking solution on the evening of incident
• Mixed dementia and non-dementia resident populations in same facility area

Coroner's recommendations

1. Consideration by the Royal Commission into Aged Care Quality and Safety of the circumstances of Mrs Boyle's death and how incidents of resident-to-resident aggression should be captured by reporting frameworks
2. Implementation of the Serious Incident Response Scheme (SIRS) with sufficiently broad scope to include incidents of abuse and aggression between aged care residents where the alleged perpetrator has assessed cognitive or mental impairment
3. Implementation of recommendations for prevention of injury-related deaths in residential aged care services, particularly Chapter 7 recommendations on reducing deaths related to resident-to-resident aggression, as published by the Health Law and Ageing Research Unit at Monash University