Inquest into the Death of Kathryn PAPANASTASIOU

Contributing factors

• Wheelchair secured using single shoulder strap contrary to Australian Standard requiring three-point restraint
• Failure to locate proper lap-sash restraint straps due to poor equipment storage and organisation
• Failure to conduct proper risk assessment when standard restraint was unavailable
• Driver time pressure and distraction from verbal aggression by third party
• Driver decision to proceed with inadequate restraint rather than remove resident from vehicle
• Lack of mandatory second staff member to monitor residents during transport
• Driver glancing at mobile phone navigation app requiring downward eye movement
• Sudden heavy braking event by driver
• Inadequate resident assessment for suitability of transport given mobility and postural control issues

Coroner's recommendations

1. Amend policy documentation to make clear that when a resident is being transported in a wheelchair, a three-point restraint system (consisting of a pelvic lap sash and a shoulder strap) must be used to secure the resident
2. To ensure straps are serviceable and available: clearly label each set of straps; conduct regular audits of straps in each vehicle; amend policy to require all straps be stowed neatly in pairs after trips
3. Amend policy documentation to mandate annual mandatory refresher training for all staff responsible for driving vehicles used to transport residents
4. Strongly urge that user guides and relevant guidance signs in community access vehicles remain visible when wheelchairs are being transported (bench seat should not obscure guidance)