Inquest into the Death of Leslie Troy OVENS
Deceased
Leslie Troy OVENS
Demographics
32y, male
Date of death
2013-07-24
Finding date
2017-04-26
Cause of death
Asphyxia in a man with Friedreich's Ataxia due to positional asphyxia; unable to recover from head-down position in which he was found
AI-generated summary
Leslie Troy Ovens, a 32-year-old man with progressive Friedreich's Ataxia, died from positional asphyxia after falling from his wheelchair. He had deteriorated significantly after hospitalisation in June 2013 and was weakened, with severe coughing fits. On 24 July 2013, no evening carer was rostered to assist him to bed due to communication failures between relief and permanent care coordinators. When the deceased attempted to move clean laundry from an airer to his bedroom—a task normally completed before the carer's arrival—he likely experienced a coughing fit, fell from his wheelchair, and was unable to reach his mobile phone or right himself. He remained undiscovered for approximately 12 hours. The coroner found systemic failures in care coordination and rostering, lack of proper handover procedures, and inadequate checks on member welfare. Key lessons: vulnerable disabled persons require robust, documented handover procedures; regular weekly rosters must reach the service user; carers need verification systems (e.g. check-in alerts) to prompt welfare checks if services are not delivered; and capacity assessments must address declining function and associated risks.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Contributing factors
- Failure to roster an evening carer for 24 July 2013 due to communication breakdown between relief and permanent care coordinators
- Absence of documented handover procedures from relief to permanent care coordinator
- Deceased was not provided with a draft weekly roster showing gaps in coverage
- Significant physical deterioration following hospitalisation in June 2013, with weakness, severe coughing fits, and reduced ability to recover from falls
- Deceased fell while attempting to move clean laundry, possibly triggered by a coughing fit
- Mobile phone rendered inaccessible after fall, preventing the deceased from calling for help
- No system in place for carers to confirm attendance or for coordinators to check on member welfare if carer did not attend
- Lack of awareness by care coordinators of the deceased's deteriorating physical state and associated risks
Coroner's recommendations
- DSC and service providers must establish clear, documented handover procedures when relief and permanent care coordinators transition responsibility for a member's roster
- All members, or their nominated representatives, must receive a draft weekly roster clearly showing all scheduled care times and any gaps in coverage
- Implement a system requiring carers to confirm their arrival and departure at a member's address (e.g. mobile app or alert system) so that failure of a carer to attend triggers an automatic welfare check by the care coordinator
- The system should include an alert mechanism: if the care coordinator has not received confirmation of a carer's attendance by a set time (e.g. 8:15 pm), the coordinator must check on the member's wellbeing
- DSC must conduct independent evaluation of Cam Can and other service providers to ensure they have adequate safeguards to detect and respond to failures in service delivery
- Care coordinators and service providers must conduct regular capacity and functional reviews of members, particularly when there has been recent illness or hospitalisation, and must communicate findings and increased risks to all relevant parties
- Service agreements must explicitly address the risks of inadequate supervision and make clear to members the consequences of choosing not to have 24-hour coverage, ensuring the decision is informed and consciously made
- DSC and service providers should establish a mechanism to ensure members understand their deteriorating functional state and the associated risks, in a manner that respects their dignity and autonomy
Full text
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