Finding into death of P L

Contributing factors

• Failure to monitor and escalate clinical deterioration of aggressive resident
• Inadequate behaviour care plan updates despite documented paranoid ideation and medication refusals
• Lack of staff training in de-escalation and occupational violence management
• Failure to implement psychiatric recommendations following review
• Absence of neurological observations post-incident despite known subdural bleed
• Deficient incident data analysis and trending
• Inadequate pain assessment and management post-incident
• Lack of care plan documentation of post-incident injury needs
• Insufficient clinical guidance systems for complex resident management
• Resident-to-resident aggression not prevented through appropriate risk management

Coroner's recommendations

1. Implement comprehensive de-escalation and occupational violence and aggression (OVA) training for all staff working in aged care facilities with residents at risk of aggression
2. Establish systematic processes for monitoring, trending, and responding to incident data with appropriate clinical escalation pathways
3. Develop and maintain updated behaviour care plans that address specific risks including medication refusal, paranoid ideation, and escalating aggression
4. Implement mandatory escalation and review protocols when residents show clinical deterioration including refusal of psychotropic medications
5. Ensure specialist mental health and psychiatric recommendations are documented, communicated, and followed up with clinical staff
6. Establish processes for post-incident neurological and pain monitoring in residents sustaining head injuries or trauma
7. Implement structured frameworks for monitoring and responding to emerging patterns of resident-to-resident aggression risk
8. Ensure care plans document and guide management of new care needs following traumatic incidents
9. Establish senior clinical guidance and complex case review systems in aged care facilities
10. Conduct further research on management and prevention of resident-to-resident aggression in residential aged care