Inquest into the Death of Ruth McKay

90y · Female·acute bronchopneumonia caused by Staphylococcus aureus

Ruth McKay, 90, died of acute bronchopneumonia after accessing the external courtyard of the Memory Support Unit (MSU) at an aged care facility undetected in the early morning of 17 January 2015. She was found under a stationary vehicle with a head injury and was transferred to hospital where she died 6 days later. The coroner found that Mrs McKay was able to exit her room and access the courtyard because: (1) sensor mats in her bedroom were not activated despite her care plan requiring them due to known wandering risk; (2) corridor doors to the courtyard could be easily unlocked from inside without alarms; and (3) there was no electronic monitoring system. The coroner found no criticism of TCH treatment including management of aspiration risk. Key preventable factors were the facility's reliance entirely on staff supervision rather than electronic safety systems, and failure to implement physical or electronic door locks despite an earlier documented similar incident with another resident three weeks prior.