Finding into death of J ZA

Contributing factors

• Inadequate training of residential support workers on substance abuse monitoring protocols
• Lack of awareness among staff of the 5-minute monitoring requirement for substance-affected youths
• Inadequate handover processes that did not facilitate access to relevant information about risk factors
• Insufficient time allocated for shift handovers
• Poor communication of policy updates to existing staff
• Inadequate induction and ongoing supervision of agency workers
• Lack of clarity regarding Care Team Meeting processes and dissemination of minutes
• Insufficient departmental auditing of residential care units

Coroner's recommendations

1. BSV reviews the staff handover process to ensure workers are allocated sufficient paid time to read all relevant materials prior to commencing a shift
2. BSV considers how to develop a system to better support residential care workers, including new or agency workers, to quickly comprehend a client's key risk factors during handover, for example through extracting key information from incident reports, monthly reports, and care team meeting minutes into a regularly updated crisis management plan
3. BSV and DFFH jointly review the Care Team Meeting process to ensure there is a clear designation of roles and responsibilities, including the taking and dissemination of minutes
4. BSV reviews the delivery of its training modules, particularly with respect to monitoring substance affected youths, and implements measures to ensure: workers are allocated dedicated, paid time to complete all required training modules; workers are assessed on their comprehension of training content; and workers receive appropriately spaced refresher training to ensure the substance of training remains at the forefront of a worker's mind
5. BSV considers implementing measures to overcome potential knowledge gaps which may be faced by agency workers, including with regard to key policy requirements
6. DFFH considers how to enhance its audit function to ensure regular audits of all out of home care residential units