Jan 19, 2024

Coroner slams facility’s quality of care after investigating resident’s death

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Coroner Simon Cooper was “not satisfied” with the care the resident received in the lead-up to his death. [Source: Google Maps]

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.”

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  1. Not good enough! Why does it take a death to ensure that equipment will be functioning properly next time! Why is equipment not tested to ensure it is working in the first place? Management you have a lot to answer for, you have denied the family the right to say goodbye to their loved one. Why had staff not done routine room/bed check? This resident was not only 98 but also had a history of falls.

  2. And here lies the problem. Why did management not take this seriously t9 begun with?? Why did the staff NOT get trained properly??? This is not good enough. An elderly man has died and who suffers? The family while the facility continues to operate.

  3. Residents should be frequently checked. Having worked in the industry for many years, this is something that should be a must!

  4. This is only one there are so many more. I have seen it with my own eyes. It is disgusting and needs to be addressed. What good was the royal commission as little has changed. Our elderly are still humans and valuable in so many ways. Remember you may be one in days to come.

  5. When my Mum was at an Aged Care facility in Hobart in 2009, I wish I had reported the treatment she was getting. I was new to all of it and was a good candidate for them to pull the wool over my eyes. She fell, broke her hip and was in her bathroom for a long time. I wasn’t told her hip was broken until she was on the slab at the Funeral Home where I helped prepare her body. When the Death Certificate was handed to me I visited the doctor who was the GP for the facility. I asked him why the certificate said that she died of pneumonia when we both knew she didn’t and why wasn’t the broken hip on the report. He told me that if he wrote that in the certificate…”it would open up a can of worms for the home”. I had to clear my Mums home for sale & get myself back to Queensland so I didn’t do anything about it. That GP committed suicide when the Royal Commission was about to begin into Nursing Homes. Can I push further with this? I don’t know….I need advice on it.

  6. Whilst it is difficult for the family to come to terms with the lack of care that contributed to their relative’s death, the apology does not equate to the extreme concern for residents and future residents. Questions must be asked as to why the detectors were not working, what systems are in place to regularly check on more fragile and vulnerable residents on a regular basis and exactly what measures are being put into place to ensure this will never happen again.
    Elders in care require regular medical care as the reason they are in care is precisely that. As we age, systems must be installed through nursing care that provides care as well as medical support. Age care providers do not just have a responsibility. They Must provide both medical and social care.


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