Finding into death of Melissa Cunningham

Contributing factors

• inadequate cleaning and maintenance of CPAP machine
• lack of documented procedures for CPAP machine management at residential care facility
• failure to conduct capacity assessment for equipment self-management
• failure to document clinical instructions in care plan
• poor communication of clinical directives across care facility staff
• possible bacterial or fungal growth in uncleaned CPAP equipment

Coroner's recommendations

1. Annecto to develop a policy and procedure for residents with CPAP machines ensuring carers: (i) conduct assessment of resident's ability to independently use, operate and/or clean the CPAP machine in conjunction with treating clinicians, with initial assessment when machine is implemented and regular reviews; (ii) document assessment results in resident's specific health management plan with strategies to support the person or directives to carers as necessary; (iii) document and record in daily case notes any assistance provided with CPAP use, operation and cleaning
2. Annecto to conduct audit of all resident care plans to ensure residents using CPAP machines have been appropriately assessed for capacity to independently use, operate and clean equipment, with results and any required directives documented in health management plans
3. Annecto to provide internal education to staff about: (i) documenting information received at medical appointments, including equipment cleaning schedules, in resident care plans; (ii) adequately documenting instructions from family members or clinicians regarding medical equipment in health management plans; (iii) complying with Annecto's Specific Health Management Policy
4. Copy of finding to be provided to Disability Services Commissioner