Finding into death of Joan Ambrose

79y · Female·Ischaemic heart disease and heat exposure with underlying cerebro-vascular disease

Mrs Joan Ambrose, 79, died of ischaemic heart disease exacerbated by heat exposure during Victoria's February 2009 heatwave at Noble Manor aged care facility. She exited unsupervised into an unprotected courtyard (46.4°C) at 1.06pm and was not discovered for three hours. The coroner found management failed to implement appropriate heat-protection policies despite adequate prior warning from government. Specifically, management should have suspended normal outdoor access policies and prevented resident wandering during extreme heat. Additionally, a planned staffing reduction (from three to two carers) during the critical afternoon shift on the hottest day compromised supervision capacity. The case demonstrates the critical importance of emergency management planning in aged care, strict control of entry/exit during extreme weather, and maintaining adequate staffing during foreseeable high-risk periods.