A coroner has revealed he was not satisfied with the quality of care a late resident received while living at a Tasmanian aged care facility after he died following a fall that went unnoticed by staff, leaving him lying on the floor to develop hypothermia.
Umina Park Nursing Home resident Aubrey Charles Reeve, 98, had a history of falls and comorbidities when he endured a final fatal fall, fracturing his hip at the Burnie facility in July 2023 after living there for about five years.
While Mr Reeve’s room was fitted with movement detectors, the facility has since confirmed they did not operate appropriately to The Mercury, meaning he was left on the floor unnoticed until care staff found him.
Coroner Simon Cooper published his findings on the incident on Wednesday and said by the time he was noticed on the floor and an ambulance arrived, attending paramedics noted Mr Reeve’s body temperature was only 34.7C. Mr Cooper said the temperate indicated he had been on the floor of his room “for some time” before he was discovered.
After attending North West Regional Hospital for the hip fracture he sustained during the fall, Mr Reeve was returned to Umina Park Nursing Home for palliative care and died four days later.
Mr Cooper has since condemned the facility for its lack of ability to provide him with Mr Reeve’s progress notes, care plans or falls assessments.
He said the treatment Mr Reeve received at the hospital was appropriate, but the care he received in the leadup to the fall was not – likely contributing to the fall that caused his death.
He said, “Clearly, steps needed to be taken to ensure, to the extent possible, that he was protected from the risk and consequences of falls.”
HelloCare reached out to OneCare which operates the facility and its Chief Executive Peter Williams said OneCare noted the findings of Mr Cooper and the organisation is already working to improve its systems and protocols to ensure such an incident did not re-occur.
He also said the organisation had already put in place procedures to ensure installed fall-detecting equipment was functioning properly and alerting staff if a fall occurred.
“On behalf of OneCare, I offer my condolences to the family of Mr Reeve and sincerely apologise to them, along with our other residents and families, for failing to meet the very high standards we expect for our aged care facilities,” he said.
“As an organisation, we strive to provide the highest quality of care each and every day and it is extremely regrettable that we failed to deliver on that commitment.
“We do not take that lightly and have a responsibility to make sure we do better.”