Feb 11, 2020

90-year-old woman died after being found outside in pool of dried blood


The ACT Coroner has heard that a 90-year-old woman died after staff found her covered in dried blood in the courtyard of the aged care facility where she lived.

Staff were unable to determine how long the woman had been outside.

This case raises one of the most difficult conundrums aged care providers face: allowing residents to maintain their dignity of choice, while at the same time ensuring their safety.

Coronial inquiry is underway

According to a report in The Canberra Times, Ruth McKay passed away at Canberra Hospital in January 2015, only six days after the incident.

Coroner Louise Taylor opened an inquiry into the tragic matter on Monday.

Mrs McKay and her husband, Douglas, moved into the Canberra facility in 2009, at first residing in the independent living section.

But six months after Mr McKay passed away, in 2013, Mrs McKay moved into the facility’s memory support unit. She had been diagnosed with advanced dementia, but otherwise remained in good health.

The incident

On the morning of 17 January 2015, staff found Mrs Mackay was not in her room. After a brief search, Mrs McKay was found lying under an ornamental car in the memory support unit’s secure courtyard. She was wearing her nightdress and had a substantial cut on her head. Mrs McKay was so weak she was unable to get up herself.

Ms Baker-Goldsmith described the scene, according to the Canberra Times report. “A large pool of dried blood was located on the concrete outside and to the left of the glass exit door, and blood spots led in a direction from the large pool towards the car.”

“A dried blood pool was observed underneath the car where Mrs McKay’s head was resting, as well as vomit observed on the concrete.

“In addition, bloody finger marks were observed on the left door of the car, as well as on a metal pole supporting the car port structure which covered the car.”

Hypothermia, pneumonia contributed to passing away

Mrs McKay was immediately taken to Canberra Hospital, but tragically she passed away six days later. 

A post-mortem found pneumonia was the cause of death. A pathologist noted that a fall and hypothermia may also have contributed to her passing away.

Everything appeared to be in order

Poniman Tju, a team leader at the facility, told the inquiry he had seen Mrs McKay in bed at 2.10am on the morning of the incident.

He noted that he had checked all external doors over the course of the shift and found they were all secure.

Mr Tju said Mrs McKay had spoken about going to see her parents and was known to have a tendency walk around the facility.

Mrs McKay had a sensor mat beside her bed that was intended to alert staff if she got up, but Mr Tju received no such alert on the night in question.

One of the problems with trying to restrict residents’ choices is facilities may not be prepared when residents act on their own wishes anyway.

The inquest continues.

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  1. The problem with sensor mats is they can be moved too easily by the resident. My FIL used to push his aside as he figured if he stood on it someone would come check on him. He also had bad falls.

  2. While working in aged care, my passion was and still is dementia. We had a number of accidents, that I feel would have been prevented or seen to in good time, had there been cameras in the rooms. I know, I know that is seen as WRONG! I helped care for a person who would switch her plugs off in her room, and then push her mat under her bed. Another would push the button to take her bed to full height! The camera would just be used for folk that needed to be kept safe…so a carer can go and put the bed down to a safe height or switch the pressure mat back on once the person has fallen asleep.


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