Finding into death of Jonathan Travis Palmer

Contributing factors

• Failure to adequately manage deteriorating health despite recognition of symptoms
• Inadequate staff training on recognizing seizure triggers outlined in Epilepsy Management Plan
• Insufficient monitoring during critical overnight period (1am-7:45am)
• Poor record keeping and documentation of health status and clinical decisions
• Lack of clear documented medical advice regarding monitoring frequency and standards
• Respiratory infection (bronchopneumonia/bronchitis) in patient with epilepsy
• Elevated inflammatory markers (CRP) potentially affecting seizure threshold

Coroner's recommendations

1. The coroner determined not to make formal recommendations, noting that appropriate preventative and restorative measures had been implemented since the death, including system-wide improvements, internal audits, and collaboration with the Disability Services Commissioner
2. The Disability Services Commissioner had previously issued a Notice to Take Action with four recommendations: (1) make all support staff aware of DSC findings, (2) train all support staff on managing deteriorating health per RSPM guidelines, (3) audit resident files to ensure contemporaneous and accurate documentation, and (4) provide training on record keeping requirements