May 18, 2018

Coroner finds aged care staff grossly mismanaged fatal attack


A 92-year-old South Australian woman who sustained a savage attack by another resident in the aged care home where she lived, was “unable to escape” and her carers exercised a “gross dereliction of proper management”, the Coroner has found.

The South Australian Coroner Mark Johns handed down his findings into the 2012 death of Dorothy Mavis Baum in an Adelaide nursing home.

Ms Baum, who was 92 at the time, was beaten with a plastic chain by another resident, Rozalia Setalo, who was 85 and was living with dementia.

Ms Baum was left lying in bloody sheet for two hours before being attended to. She died the following day from her injuries.

Mr Johns found that the two nurses in attendance at the time of the incident exercised a “gross dereliction” in their care of Ms Baum.

Registered nurse Ute Latz and carer Harit Kamal barricaded themselves in the nurses’ station during the attack, and did not deal with Ms Setalo, because of the risk they believed it would expose them to.

But Mr Johns said that both the nurse and the carer were “duty bound” to take on some risk during the incident because if they didn’t, residents, who were relatively much more vulnerable, could be injured.

When Ms Baum was finally discovered after the attack, Mr Johns said she was not sent to hospital quickly enough.

Mr Johns also said that Ms Latz and Mr Kamal delayed a proper investigation into the incident by suggesting that Ms Baum had inflicted the injuries on herself.

Mr Johns said the fact that those who were managing the nursing home at the time of the attack escaped sanction was “entirely inadequate”.

Operational changes introduced to the Commonwealth Aged Care Framework in 2018 would mean senor management and nursing home boards would have to be more accountable, the Coroner said.

“Only by adopting a scheme in which there is some personal risk to those involved in the management of aged care providers at the highest level could the public be confident that an event such as the appalling treatment of Mrs Baum in life and then in death could not happen again.”

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  1. I cannot believe it, it was a plastic chain, surely 2 staff could grab the chain, one staff to hold her, even if they needed to throw a blanket over her. One staff should have rang the ambulance and that staff checked the injured resident. There appears to be a lot of ways it could have been handled. I had a man that had a large knife held up in the air ready to stab another resident (he was in a wheelchair) I came behind, grabbed his wrist and took the knife. All staff were locked in their rooms, ambulance called, family called all the paper work done when he was taken.

  2. Staff have so many rules placed on them on restraining residents this does not surprise me. In 2021 you cannot restrain anyone! If you get hurt management blame the staff for not observing the situation properly. Dambed if you do dambed if you don’t. Where are the 24 hour security guards in nursing homes? Obviously it is needed. The rules on violent patients in Hospitals are so very different to “Residential” aged care facilities.In hospitals the Nurses have an alarm on their uniforms and security appear soon after. AINs are not security! A joke on all the staff. A disgusting blight on an industry that has a mindset that simple AINs and Nurses have a “duty of Care” to the residents way before the duty of care to the staff who are working on a skeletal no of staff at any given time. I suppose you would have to have been there!

    1. Residents can be restrained in an emergency situation such as this, however staff are not trained to manage and de- escalate these situations. At the very least, if two nurses felt unable to deal with the situation and had locked themselves in the office, they should have called police and ambulance for assistance.
      On the statement relating to mental health units, I heard recently of a nurse who was badly injured when attacked by a patient. The issues there were 1) she was the only staff member in the unit at the time, 2) two security guards who were on duty were both outside having a cigarette!
      In both hospitals and aged nurses care facilities there is a culture of blame, what did you do or not do to provoke (or prevent) the incident.
      So many things need to change across the entire health system.

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