An inquest has cleared aged care provider Bolton Clarke of any wrongdoing following the tragic death of 89-year-old Robert Driver, who was fatally injured by another resident in an unprovoked attack at a Lake Macquarie facility.
Mr Driver, a former lieutenant in the Royal Australian Air Force, was a resident of the Long Tan Unit at Macquarie View Retirement Village in Bolton Point when he was attacked by another resident with dementia on 20 August 2020.
The incident occurred when Mr Driver was being escorted to his room after dinner. The aggressor pushed past the staff member, struck Mr Driver in the face, and caused him to fall and hit his head against the corridor wall.
A neurological assessment was conducted shortly after the incident, and Mr Driver initially showed no signs of pain. However, by the early hours of the morning, he began to complain of neck pain.
Medical assistance was sought, and he was transported to John Hunter Hospital, where scans revealed a type 3 fracture at the base of the odontoid peg. Due to his condition, medical professionals advised non-operative management with an Aspen collar, with comfort-based care as an alternative if he could not tolerate it.
Despite these interventions, Mr Driver’s condition deteriorated, and he passed away on 25 August. An autopsy confirmed cervical spine trauma as the cause of death but found no evidence of intracranial injury or skull fracture.
Following the coronial investigation, Magistrate Derek Lee ruled that Bolton Clarke’s response to the incident was appropriate. NSW Police also declined to pursue criminal charges in relation to the death.
Associate Professor Sally McCarthy, who reviewed the case, concluded that Mr Driver’s pre-hospital care was graded and responsive to his worsening condition, deeming the management “adequate and appropriate.”
In response to the incident, Bolton Clarke has made several changes to its policies and procedures. Katherine Platt, General Manager of Clinical and Service Governance, provided a letter to the court detailing a review of resident selection guidelines, particularly concerning behavioural and psychological symptoms of dementia.
A new falls management guideline was also introduced following a major review in July 2020. This update included structured post-fall management procedures to be followed by both clinical and non-clinical staff.
While Mr Driver’s death was a deeply distressing event, the inquest findings have underscored the complexities of managing residents with dementia and the ongoing need for aged care providers to implement stringent safety measures.
The improvements made by Bolton Clarke reflect an industry-wide commitment to enhancing care protocols and ensuring the well-being of residents in aged care facilities.
The distressing part of this story is that it took the loss of life to effect a change that should have been considered.
Dementia is not a new disease and there are experts in this field that can be consulted.
At this stage, we should not be in a position that we need to invent better ways when there have been countless international studies that document known risks.
If he was receiving services to support him to live at home, he would not have been exposed to this risk.