Coronial findings (decisions) 2022-2023

Response received from Department of State Growth, State Roads Division 2 October 2023

I note the record of investigation and findings, handed down on 26 June 2023, with respect to the deaths of Judith Anne Riley and Donald Roy Riley. A copy was provided to the Department by your office on 15 September 2023.

The record of investigation noted a report from the Department of State Growth that indicated that slippery when wet signs were to be provided as an interim measure on this section of the West Tamar Highway, with resealing works to occur at a later date.

I can confirm that the Department completed resealing works at this location in February 2022 as part of its annual maintenance program, improving skid resistance of the road surface. A skid resistance survey will also be conducted to confirm the effectiveness of this treatment.

Response received from Queenborough Rise 16 August 2023

Following the death of Mrs Hazell we developed a tool within our clinical care system to prompt staff to conduct regular safety checks of all chair sensors within the facility. This tool reminds staff to conduct a safety check every shift. This observation is then documented within our clinical care system.

Correspondingly, the ‘Purposeful Rounding Chart’ was reviewed and now includes the following check: “Check if the resident has a bed sensor, chair sensor calls bell and/or pendant-functioning and or near the resident before leaving the room”. This chart contains a list of actions that must be undertaken for each resident every hour.

As well, every six months scheduled testing of the nurse call bell system is competed by an external provider. The chair sensor mats work through this system. The scheduled testing was last completed in May 2023.

Other measures we have taken include

• The Coroner’s findings were discussed at our local site quality meeting and the actions were documented in our Continuous Improvement Plan.
• The Coroner’s findings were discussed at the Regional Executive Team meeting. This meeting is attended by all senior clinical managers from around the state. As a result all sites now closely monitor the use of motion chair sensors
• The Coroner’s findings were also discussed in the Senior Executive Team meeting.

Response received from Clarence City Council 16 August 2023.

In the report published, there was reference to a heavy indentation known as a rut on the gravel road edge approximately 50 metres from the crash site. As noted in the report, the rutting in the road edge is triggered by road users cutting through the shoulder of the road. The report states that the rut was not identified as a contributing factor to the crash.

The recommendation of the report was made for Clarence City Council to ‘assess this rut and repair it if the assessment deems it necessary’. This was reported in the Mercury newspaper article of 20 June 2023 titled ‘Snapchat posts 12min before fatal ute crash’. Council was not consulted before the publication of the report or article.

In reference to the Coroner’s recommendation to council, I can confirm the gravel road edge is part of council’s ongoing road maintenance program and repair of the rut was undertaken between 19 August and 19 September 2021, within weeks of the death of Mr Oates. Since this time the road has been re-edged as part of regular maintenance in the area, most recently in early 2023. Council acknowledges the rutting is prone to regression given the practice of road users cutting the corner and driving on the gravel edge.

Council is committed to maintaining council roads to providing safe roads for all users. The rut is on council’s maintenance schedule and will continue to be maintained as part of council’s road maintenance program.

Response from Corumbene received 3 May 2023

Corumbene has taken the following actions since receiving the Coroner’s recommendations:

* Reviewed policy and procedure concerning falls, risk assessments and associated matters.

* Initiated a staff education and display reminder on the importance of Falls Risk Assessment Tool (FRAT) assessments.

* Completed a spot check audit on individual residents’ suitability of FRAT risk.

* Reviewed and increased contracted physiotherapist services and implemented and enablement and falls risk component to the service.

* Implemented a physiotherapist post fall review process.

* Executed annual, or as needed, allied-health functional assessments, including exercise programs and equipment prescription.

* Increased clinical oversite with the recruitment of two (2) care managers and regular senior clinical care meetings which focus on specific clinical care  needs of high-risk residents.

* Implemented a falls committee meeting bi-monthly.

* Improved clinical incident response and investigation governance oversight.

Response from Respect received 23 August 2023.

In response to the first recommendation, I recommend that all facilities using mobility hoists review their maintenance schedules to ensure that they are serviced at intervals which are appropriate to detect and prevent failure of the components, the following has occurred:
 Review of policy and process.
 Review of the preventative maintenance process indicated that monitoring of schedules could be improved, thus improvement has been facilitated by the introduction of an electronic recording and monitoring system, replacing the previous paper-based system.
Following trial, this system is being rolled out throughout the organisation.

In response to the second recommendation, I recommend that technicians responsible for servicing mobility hoists use thread locking adhesive (such as Loctite) and/or split pins to provide additional. security to critical, load-bearing nuts and bolts, the following has occurred:
 Respect have consolidated service agreements for preventatve maintenance of hoists to have two service providers over three states. Discussions with service providers has indicated that technicians are unwilling to make any changes to the manufactured structure of hoists given that they may be accountable for liability of any failure. Additionally, warranties would be voided.
 To mitigate the risk of further incidents in addition to regular external annual service and checks the internal Respect maintenance staff undertake monthly checks of all hoists with particular attention to nuts and bolts.
 Servicing of hoists continues to be undertaken as per the manufacturer’s recommendations..

Response from Veterinary Board of Tasmania received 4 September 2023

The VBT recently declared revised veterinary service standards and guidelines.

https://nre.tas.gov.au/Documents/Tasmanian%20VSS%20-%20Standards%20and%20Guidance%20Notes.pdf

On page 42 the Guidelines state the following with respect to storage of Pentobarbital:

Pentobarbital

Appendix D of the Poisons and Therapeutic Goods Regulation 2008 (Regulation) lists Schedule 4 substances (prescription-only medicines) that have common therapeutic uses, but are also liable to abuse, misuse and diversion, warranting more stringent controls on possession and supply. These substances are commonly referred to as Schedule 4 Appendix D (S4D) medicines. S4D substances must be stored in a locked container and kept securely when not in immediate use. The Board expects that Pentobarbital be stored in an S8 safe to prevent unauthorised access.