A coronial inquest has commenced in Victoria following the deaths of eight elderly residents in aged care facilities, all linked to acts of aggression from fellow residents.
The incidents occurred over a nine-month period in 2021, prompting a wide-ranging examination of how aged care services manage and prevent harm between residents, particularly those living with dementia.
The tragic events took place across six facilities: Shepparton Villages, Samarinda Lodge in Ashburton, the Noel Miller Centre in Glen Iris, the Peter James Centre in Forest Hill, Narracan Gardens in Newborough, and The Alexander Aged Care Centre in Clayton.
Each death followed a physical altercation in which a resident was either pushed or struck by another individual also residing at the facility. Many of the victims were frail, with existing health conditions that made them especially vulnerable to injury.
Five of the deaths were the result of hip or pelvis fractures after a fall, while the remaining three were due to subdural haematomas.
The inquest will determine whether these incidents could have been avoided through improved care or earlier interventions.
Deputy State Coroner Paresa Spanos is presiding over the inquiry, which aims to uncover systemic shortcomings, assess whether residents were appropriately placed within their facilities, and consider whether current safeguards are adequate to protect those at risk.
Counsel assisting the coroner, Naomi Hodgson, explained that many of the individuals responsible for the harmful acts were experiencing significant cognitive decline.
Research presented to the court indicated that nearly 90 per cent of people involved in fatal resident-on-resident altercations had been diagnosed with dementia. Rather than being motivated by malice, these behaviours are often impulsive and the result of dysexecutive function – a condition that impairs a person’s ability to regulate their actions.
“These cases involve cognitive impairment and impulsivity,” Ms Hodgson said. “The consequences of such behaviour are far more serious in aged care settings, where residents are physically frail.”
The court was told that personal history, cultural background, unmanaged pain, medication side effects, and environmental conditions such as poor lighting and excessive noise may all contribute to incidents of aggression.
While the federal government has implemented a three-tiered framework to address complex dementia-related behaviours — including advisory services, response teams, and specialised dementia care units – the availability of these services remains limited.
Even when all units are operational, there will be fewer than 300 specialised beds across the country.
Ms Hodgson said that understanding both the behavioural drivers and environmental triggers for aggression is crucial, particularly as Australia’s aged care sector cares for an increasing number of people living with dementia.
In 2021, an estimated 240,000 people lived in residential aged care across the country, with between 54 and 70 per cent experiencing dementia.
The inquest will review whether more robust systems, different care arrangements, or timely interventions could have altered the outcomes in each of the eight deaths.
The findings may lead to formal recommendations aimed at strengthening protections for vulnerable residents, especially those at risk of impulsive or aggressive behaviour from others.
The hearing is expected to run for five days, with the goal of identifying patterns, shortcomings, and potential reforms within aged care facilities to prevent future harm.
The facilities involved should be held accountable; they are responsible for the safety of ALL residents in their facility.
Staff need to be trained to a standard that keeps people living with dementia in an environment that is conducive to calming them, as well as being able to divert behaviours when they occur.
Staff numbers need to be set higher in facilities where people living with dementia reside. there is NO excuse for aggression getting out of control.
If this needs to be taken back to the government to demarned further funding for staff and whole of facility training, so be it.
Having worked and managed an aged care facility, it is very difficult to manage some behaviours. You can’t use restraint as an option, and it’s criticised if you use medication. We can do up a referral to Dementia Support Australia and hope they can help. Staff get exhausted, and there’s no additional funding. It’s almost impossible to get the resident into a specialist dementia unit as there is a long wait list.
I am not sure what the provider is meant to do despite the hospital being unable to manage it. The provider is expected to adhere to heaps of regulations that don’t protect staff or residents. The usual advice is, you’re not doing enough.
Perhaps funding for one-on-one care could be beneficial. Dementia Support Australia provides exceptional assistance, backed by well-trained professionals, though they can only do so much. The families and the commission making the providers accountable are not the solution; 99% of us have every action possible in place, apart from 24/7 security, and that’s never going to work.