Finding into death of Elizabeth Ethel Watson

Contributing factors

• Inexperienced enrolled nurse rostered as nurse in charge on third shift without adequate supervision
• Lack of access to electronic medical records system (Autumn Care) by nursing staff
• Failure to recognise severity of injury on initial assessment
• Inadequate clinical documentation of fall and post-fall assessments
• Delay in medical evaluation (5 hours post-fall)
• Locum general practitioner diagnosis of soft tissue injury without identifying fractures
• Failure to escalate clinical deterioration overnight
• Delayed hospital transfer (overnight to following day)
• Inadequate staffing levels and management oversight at facility
• No contemporaneous incident reporting completed

Coroner's recommendations

1. Implement formal investigation procedures immediately following serious incidents, including file reviews and formal written statements from all staff involved
2. Ensure adequate staffing levels with experienced nurses in supervisory positions, particularly on weekends
3. Provide all staff with login credentials and access to electronic medical records systems prior to commencing shifts
4. Conduct mandatory training on recognition and escalation of clinical deterioration, particularly in elderly patients with fractures
5. Implement training on pain management and appropriate use of escalation procedures
6. Ensure robust documentation practices with contemporaneous incident reporting
7. Develop clear communication protocols with families regarding resident incidents and changes in clinical status
8. Implement post-fall flowcharts requiring hospital transfer for any change in clinical status
9. Ensure staff do not rely on single practitioner assessments; staff should undertake independent clinical assessments
10. Establish contact protocols with general practitioners to ensure continuity of coverage and knowledge of locum arrangements
11. Work towards Royal Commission into Aged Care Quality and Safety recommendations of 200 minutes of care per resident per day, with 40 minutes being registered nurse care