A coronial inquest in South Australia is examining whether the care provided to a resident at a metropolitan aged care home was appropriate in the weeks before his death, with a particular focus on the management of pressure sores that developed as his health deteriorated.
The inquest, being heard in the South Australian Coroners Court, concerns the death of John Michael Henry Allen, who died at the Royal Adelaide Hospital in September 2022 at the age of 79. Mr Allen had been living with advanced Alzheimer’s disease and was a resident of Bupa Enfield in Adelaide’s northern suburbs.
Counsel assisting the coroner told the court the inquest will investigate whether the treatment of Mr Allen’s pressure injuries between July and August 2022 was appropriate and reasonable, and whether different management of those wounds may have altered the outcome.
Mr Allen had been diagnosed with advanced Alzheimer’s disease in 2016 and moved into residential aged care in 2019. According to evidence presented at the opening of the inquest, he was transferred to hospital on 21 August 2022 after family members became concerned about his condition and mobility.
Hospital staff identified a significant necrotic wound on his buttocks and a stage three pressure ulcer on his foot. He was treated with intravenous antibiotics, wound dressings and regular pressure care. However, his health continued to decline, complicated by poor oral intake, dehydration and other medical issues.
He was transferred to palliative care on 1 September before dying eight days later. His cause of death was recorded as advanced Alzheimer’s dementia with a background of pressure sores.
Evidence heard so far has outlined the care provided by nursing staff at the aged care home before Mr Allen’s hospitalisation. Nurses told the court that wound management plans were developed and dressings applied after pressure injuries were identified. Staff also documented the wounds through photographs and, at one point, administered antibiotics.
The court heard Mr Allen was non-verbal due to his dementia, requiring staff to assess pain through facial expressions, body language and resistance to care. Nurses gave evidence that he appeared to be experiencing pain in the weeks before his death.
One nurse told the court she identified a pressure injury on Mr Allen’s foot on 20 August 2022 and recommended it be reviewed by a general practitioner. She also advised staff to reposition him every two hours, a standard pressure injury prevention measure.
Pressure injuries, sometimes referred to as bed sores, are areas of skin and underlying tissue damage that can develop when prolonged pressure restricts blood flow. Older people living with dementia, reduced mobility or complex health conditions are at increased risk, making prevention and early intervention a significant focus of aged care clinical practice.
The coronial process is not intended to determine criminal liability. Instead, it examines the circumstances surrounding a death and can result in recommendations aimed at improving public safety and preventing similar deaths in the future.
The inquest is expected to hear further evidence from clinical staff and experts as it considers whether the care provided to Mr Allen met expected standards and whether opportunities existed to prevent the progression of his wounds.
