Finding into death of Arto Aaro Bohm

Contributing factors

• Inadequate pressure ulcer prevention strategies despite high-risk Waterlow assessment scores
• Failure to implement hourly repositioning as recommended by Western Health (only 4-hourly implemented)
• Lack of pressure relief equipment despite facility policy indicating need for bariatric bed and specialized mattress
• Delayed and incomplete wound documentation and assessment
• 6-day delay in commencing sacral wound assessment after wound specialist identification
• Poor quality wound charting with missing objective measurements and pressure injury classification
• Misapplication of 'dignity of risk' policy to justify withholding basic hygiene care
• Failure to reassess patient decision-making capacity despite clinical evidence of limited insight
• Lack of communication with guardian regarding refusal of care and treatment refusal
• Failure to escalate concerns to Office of Public Advocate regarding need for substitute medical decision-maker
• Poor GP record-keeping with no documented notes in facility progress notes despite weekly visits
• Patient sleeping in wheelchair overnight, exacerbating wound issues
• Multiple comorbidities: Type 2 diabetes, obesity, respiratory failure, incontinence, lymphoedema, chronic wounds

Coroner's recommendations

1. Aged care facilities should implement pressure ulcer prevention strategies that meet or exceed their own policies, including appropriate frequency of repositioning (hourly as recommended rather than 4-hourly) and pressure relief equipment
2. Comprehensive and objective wound documentation should be maintained, including measurements, pressure injury staging, infection signs, and photographic evidence
3. Facilities should reassess decision-making capacity regularly, particularly when patients refuse care, using validated capacity assessments and clinical judgment
4. When patients refuse care that poses health risks and capacity is questioned, escalation to guardians, substitute decision-makers, and senior clinicians should occur
5. The concept of 'dignity of risk' should not be used to justify withholding basic hygiene and skin care; professional discretion must be exercised to prevent harm
6. General practitioners attending aged care facilities should document their assessments and recommendations in facility progress notes to ensure continuity of care
7. Early mental health intervention should be considered for residents demonstrating continuous refusal of care, with timely referral for assessment
8. Staff should receive regular training on pressure injury identification, wound assessment, skin health, and the importance of objective record-keeping
9. Facilities should maintain clear escalation pathways for complex cases and use these pathways when care needs exceed facility capacity