Dec 20, 2022

National aged care death register could offer comfort to families

20_12_22 death register

Warning: Aboriginal and Torres Strait Islander readers are advised that this article contains the name of a person who has died.

Calls have been made for the establishment of a national register of aged care deaths following a facility’s ‘cagey’ behaviour surrounding the death of an Indigenous man who died on the footpath outside his eastern Victorian nursing home.

On May 15 this year, 70-year-old Dennis Miller was found following a suspected fall with facial wounds in a pool of blood and vomit on the footpath outside his room at the Royal Freemasons Moe Aged Care Facility in Gippsland. 

His family have been fighting since to have his death investigated to find out what happened.

As this investigation unfolds, Professor Joseph Ibrahim from Latrobe University’s Australian Centre for Evidence-Based Aged Care said there should be a transparent register of all deaths in aged care homes.

It was something he lobbied for in his submission to the Royal Commission into Aged Care Quality and Safety where he presented a compilation of case studies from all aged care deaths investigated by State Coroners across the country to educate staff in the sector.

In the three months leading up to September 30, 2022, 232 “unexpected deaths” in nursing homes were reported to the Aged Care Quality and Safety Commissioner.

But Professor Ibrahim believes that number is much bigger and noted that the definition of “unexpected deaths” under this scheme has never been properly defined.

“Every death should be registered in aged care in a central place that can be analysed… so we’re able to keep improving the system,” he told ABC.

If a national register of aged care deaths was in place, families, like Mr Miller’s, would be able to get proper closure.

Causes of death investigated

Clearer reporting of aged care deaths would have prevented Mr Miller’s daughter, Samantha Mowatt, from having to chase up the confusion around her father’s death and whether it was reported to the Victorian Coroner.

A death is reportable to the State Coroner when the death occurs in custody, is unexpected, unnatural, violent, a result of accident or injury, or involving a mental health patient.

Four progress notes were written in the hours after Mr Miller died, documenting interactions with him in the 12 hours before his death. These notes showed he was given two doses of oxycodone, a prescribed opioid pain-relief medicine, the night before his death.

But staff also documented that Mr Miller had been drinking alcohol and “appeared intoxicated”.

When Mr Miller’s doctor, Robert Birks, signed Mr Miller’s death certificate, he noted “cardiac arrest” as his cause of death, which is not reportable to the Coroner.

But according to the death certificate, Dr Birks did not see Mr Miller’s body.

In July, when Ms Mowatt learnt her father’s death would not be investigated, she wrote to the Office of the Victorian Coroner and put in a complaint to the Aged Care Quality and Safety Commission.

A spokeswoman for the Victorian Coroner’s office said it was “reviewing available evidence to determine if the death is reportable” and if an investigation should be initiated.

The Victorian Coroner is now investigating Mr Miller’s death along with three other former residents who died at the same nursing home between July 2020 and November 2021. The Federal Regulator and the Aged Care Quality and Safety Commissioner are also investigating the facility.

In a statement, Royal Freemason’s Chief Executive, John Fogarty, confirmed the Aged Care Quality and Safety Commission and the Victorian Coroner were investigating Mr Miller’s death and it would cooperate with the investigation.

“The staff on duty at the time of Mr Miller’s death followed appropriate protocol to inform police who attended and police made the decision to refer the death to the coroner,” Mr Fogarty said.

“It would not be appropriate to comment further until these investigations are complete.”

Ms Mowatt has fought for months to find out about the events leading up to her father’s death and whether the facility was guilty of negligence. The family have not been able to have the closure they were hoping for around Mr Miller’s death.

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