A Queensland aged care facility is under scrutiny after an 85-year-old resident with dementia died following prolonged exposure to the sun, and staff revealed a similar incident nearly occurred with another resident.
The man, living at Kerrisdale Gardens Aged Care in Mackay, operated by the Anglican organisation Good Shepherd Lodge, was found in the unshaded outdoor area more than two hours after leaving the memory support unit in his motorised wheelchair. Temperatures on the day reached 30 degrees Celsius, and by the time paramedics treated him, his body temperature had climbed to 40.6 degrees. He later died in hospital from heat stroke, with pre-existing conditions including Alzheimer’s and vascular dementia worsening the impact.
The coroner investigating the case described the death as a preventable tragedy, highlighting staff failures to perform regular visual checks on residents. The facility had implemented an “hourly sight charting” system, meaning each resident should have been observed every 60 minutes. On the day of the incident, the man was not seen between 10am and 12.20pm.
Good Shepherd Lodge chief executive Tracey Duke acknowledged the tragedy and confirmed a second resident narrowly avoided harm in a similar situation the following month. She said the facility had addressed the issues through staffing adjustments, enhanced training, updated procedures, and stronger supervision protocols.
“The contributing factors for both incidents have been fully addressed and the second resident was not harmed,” Ms Duke said. She added that the Aged Care Quality and Safety Commission had conducted a review and confirmed the site was now fully compliant.
An external audit of Kerrisdale Gardens had previously identified a range of concerns, including inadequate management of wounds, falls, medications, and pain. Chemical restraints were occasionally used without documentation, and risk assessments for psychotropic medications were sometimes missing, potentially increasing the risk of drowsiness, dizziness, and falls.
Ms Duke said the facility had introduced new policies, daily team meetings, updated menus, improved infection control measures, and higher staffing levels. Nurses Professional Association of Queensland president Kara Thomas said Kerrisdale Gardens’ turnaround was one of the best improvements she had seen, praising both management and new staff for their dedication.
Since the incident, the facility has also installed alarms on garden doors and implemented a two-person authentication system to ensure wandering residents are supervised. The staff member responsible for the initial oversight was terminated and reported to the Office of the Health Ombudsman.
While the facility has made significant changes, observers note that the true test will be maintaining these standards consistently over time to prevent similar tragedies from occurring again.
