VICother

Finding into death of Russell Leslie James Hewat

Deceased

Russell Leslie James Hewat

Demographics

33y, male

Date of death

2021-11-06

Finding date

2024-09-05

Cause of death

Aspiration pneumonia in the setting of recent COVID-19 infection

AI-generated summary

Russell Hewat, a 33-year-old man with autism, Down syndrome, intellectual disability, and dysphagia, died from aspiration pneumonia following COVID-19 infection. He was discharged from Frankston Hospital on 1 November 2021 and readmitted to Warragul Hospital on 3 November with DVT, discharged again on 5 November. During the night of 5-6 November, agency staff raised concerns about Russell's coughing and vomiting; Aruma staff dismissed these concerns. Russell deteriorated and died on 6 November. The coroner found opportunities were lost to call an ambulance earlier, primarily due to Aruma's failure to appreciate or escalate concerning symptoms, poor communication between shifts, lack of handover procedures, and inadequate support for both permanent and agency staff. Whilst not finding the death preventable, the coroner identified systemic failures in the disability service provider's workplace culture, documentation, and escalation protocols.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

emergency medicine intensive care physiotherapy occupational therapy

Error types

communication system delay

Clinical conditions

aspiration pneumonia COVID-19 infection deep vein thrombosis dysphagia autism spectrum disorder Down syndrome intellectual disability

Contributing factors

Failure of Aruma staff to appreciate significance of symptoms of coughing and vomiting
Dismissal of concerns raised by agency disability support workers
Lack of effective handover procedures between shifts
Insufficient communication of clinical information to agency staff
Absence of definitive policies and procedures regarding escalation of concerns
Poor documentation and communication systems
Unsupported workforce with unclear role responsibilities
Lack of training on recognition of clinical deterioration for non-medical staff
Failure to implement findings from internal investigation

Coroner's recommendations

Aruma Disability Services should advance without further delay the implementation of a handover policy that is both rigorous and supports its workforce to effectively deliver handover between shifts by providing appropriate compensation to facilitate this handover crossover time
Aruma Disability Services should implement and mandate training on escalation – escalation on the type of situations and/or change in conditions that should be escalated by disability support workers

Full text

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Source and disclaimer

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