The death of an 85-year-old man at a Queensland aged care facility has been deemed a preventable tragedy by Coroner Carol Lee, following an investigation into his passing after being left unattended in direct sunlight for over two hours.
The incident, which took place in February of last year, unfolded when the elderly resident was found unconscious beside his wheelchair in the facility’s garden, as temperatures reached 30 degrees Celsius.
According to findings from the coroner, the man was exposed to extreme heat without shade, resulting in severe “environmental exposure.” Staff at the facility discovered the resident after he missed his scheduled midday medication.
Despite immediate efforts by paramedics, including applying ice packs and wet towels to cool him down, the man was transported to the hospital suffering from hyperthermia, severe blistering, and burns. Tragically, he died days later from heat stroke, worsened by pre-existing conditions such as Alzheimer’s disease and vascular dementia.
The investigation revealed the man had a history of falls and displayed a “very determined manner,” making it difficult for staff to dissuade him from activities he wanted to pursue.
His wife, who did not live at the facility, had agreed that it was important to support his desire for autonomy, as it gave him a sense of purpose. As part of his care plan, an “hourly sight charting” procedure was approved, meaning that a nurse was supposed to check on him every 60 minutes to ensure his safety. However, the coroner found that on the day of his death, no staff member had checked on him for more than two hours.
Coroner Lee was unequivocal in her conclusion: “[The death] occurred in the context of staff failure to undertake periodic visual safety and wellbeing checks,” she said, adding that the tragedy was entirely preventable.
Following the man’s death, the facility underwent a comprehensive investigation by the aged care regulator. While the coroner acknowledged that significant changes had since been implemented to improve safety, the oversight leading to the man’s fatal heat exposure highlighted serious gaps in care.
The facility has since taken measures to prevent such an incident from occurring again, including providing additional staff education on the importance of completing sighting charts.
A two-person authentication process has also been introduced for residents known to wander, ensuring multiple staff members confirm their whereabouts. In addition, an alarm system has been installed on garden doors to notify staff when a resident leaves the building, bolstering the safety of vulnerable residents.
The staff member responsible for failing to carry out the required safety checks has been terminated and reported to the Office of the Health Ombudsman, according to Coroner Lee.
She expressed confidence that the combination of these changes would prevent a similar tragedy in the future, saying, “I am satisfied that the combined effect of these strategies will prevent a similar incident from occurring again.”
