Finding into death of Gwenyth Evelyn Miles
Deceased
Gwenyth Evelyn Miles
Demographics
88y, female
Date of death
2019-04-28
Finding date
2022-05-11
Cause of death
Multisystem organ failure in the context of exposure, humeral fracture, and clinical dehydration
AI-generated summary
An 88-year-old woman with Alzheimer's dementia resident in aged care left the facility undetected on a hot day and collapsed 800-900 metres away with a humeral fracture. She died nearly two months later from multisystem organ failure secondary to exposure, fracture, and dehydration. The alarm bracelet system designed to alert staff to her departure failed to sound. Clinical lessons include the tension between residents' liberty and safety in aged care; the limitations of technological solutions (alarm bracelets); and the critical importance of direct staff monitoring of exit points. A dedicated person monitoring the front door would have been the most practical preventive measure. This case illustrates systemic challenges in managing wandering risk in dementia residents while respecting autonomy.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Contributing factors
- Dementia (Alzheimer's)
- Failure of alarm bracelet system to function
- Absence of direct staff monitoring of front door during shift changeover
- Opportunistic departure coinciding with reception desk staffing gap
- Lack of vestibule at front entrance
- Prolonged door opening time allowing resident departure
- Delayed response to initial report of resident collapse
Coroner's recommendations
- Arcare Brighton to review staffing and infrastructure arrangements at the front door with a view to having doors which open automatically to allow entry while being directly monitored by staff
- Arcare Pty Ltd to consider such a review at other facilities with the view to maximising residents' liberty and at the same time optimising their safety
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