Nov 16, 2023

Aged care resident not given CPR, dies due to staff’s fatal mistake

Tandara Lodge
The provider has since said they have made changes to their policies and protocols to prevent this from happening again. [Tandara Lodge website]

A Coroner has found an aged care resident who died from a heart attack in his room at a Tasmanian residential aged care facility was not given CPR because staff mistakenly believed he had an active “do not resuscitate” order.

Wayne Victor Rouse, 68, lived at Tandara Lodge at Sheffield where he began feeling the impacts of cardiac failure the morning of June 14. He pressed his call bell for carer assistance but the carers on duty were with another resident, tending to Mr Rouse eight minutes after the call where they found him on the bathroom floor, unconscious with no pulse. 

Staff mistakenly believed Mr Rouse was not to be resuscitated and did not perform CPR, however, they did activate the emergency call system to call a Registered Nurse (RN) before an ambulance was called. Mr Rouse was pronounced dead about 15 minutes later. 

In his findings, Coroner Robert Webster revealed staff located records after his death and discovered Mr Rouse had an active resuscitation order which was determined to be from heart failure. 

“Mr Rouse died in very unfortunate circumstances,” Mr Webster said in his findings.

Mr Webster confirmed Mr Rouse had a range of medical issues including congestive cardiac failure, hypertension and chronic obstructive pulmonary disease which contributed to his death.

Pointing to the aged care facility’s inadequate documentation and communication processes as the reason for the fatal mistake, Mr Webster did suggest had Mr Rouse been resuscitated, the medical evidence “appears to suggest he would not have been revived.”

Coronial Nursing Consultant Kevin Egan assisted Mr Webster with the investigation into the resident’s death and found his medical wishes were not “immediately available” to staff and on the evening before the incident, only one RN and one care worker were rostered on to work.

The Coroner recommended that the facility review its staffing levels and ensure it has enough staff members rostered on.

Mr Egan confirmed that since the incident, the facility had identified, documented and implemented a series of changes to address its inaccuracies in communication and documentation and prevent a similar incident from happening again.

Some of the changes included colour-coded signs in residents’ rooms to indicate their resuscitation wishes, standardised and localised document storage, and updated and approved “goals of care” information for all residents.

Tandara Lodge Chief Executive Officer (CEO) Paul Crantock expressed his condolences to Mr Rouse’s family and confirmed the facility implemented changes promptly after his death. He also flagged difficulties in attracting and hiring staff in the area. 

“We definitely have taken on board the comments the Coroner made [and are] hopeful to have that [night shift] position filled in the near future,” he told Nine News.

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