Coronial findings (decisions) 2023

Response provided by Tandara Lodge received 16 April 2024

Quick and easily identifiable resuscitation protocols for each resident have been implemented with multilevel safeguards which include:

• all residents have an updated and approved goals of care form signed including temporary and respite residents;
• colour-coded signs in the residents' rooms indicate their resuscitation status;
• there is standardised and localised document storage in the common staff area for all residents' goals of care documents;
• there is a quick reference system on the registered nurse keyring to identify those residents for resuscitation;
• staff education and training has been undertaken to update all staff on the changes made and location of key documents and plan; and
• the not for resuscitation section on the staff handover sheet has been removed in order to eliminate it as a potential source of incorrect information and input error."

In addition to the above, and in line with the recommendation made by the Coroner we reviewed staffing levels and have now created an additional staff member position on night shifts. This increases the staffing levels on night shift by 50%.

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 received from Consumer Building and Occupational Services  1 December 2023

As an industry regulator, one of the roles of Consumer, Building and Occupational Services (CBOS) is managing the occupational licensing of tradespeople and pursuing complaints relating to unlicensed or defective building work in accordance with the Occupational Licensing Act 2005. If a complaint is substantiated, CBOS can take various compliance actions, including suspending or cancelling licences, and prosecuting offences.
Additionally, CBOS has a role to play in managing risks posed to consumers by dangerous goods, by ensuring goods meet safety standards in accordance with the Australian Consumer Law (Tasmania) Act 2010. CBOS has authority under this Act to take enforcement actions as a result of breaches of consumer safety standards. Accordingly, wholesalers and retailers of chainsaws must ensure imported tools are safe, meet Australian Standards and are fit for purpose. Traders, importers and manufacturers are also obliged to promote products in ways that meet mandatory standards intended to prevent or reduce the risk of injury. CBOS undertakes investigations and audits to ensure consumer goods comply with the relevant standard.
As a result of Coroner Simon Cooper’s investigation and recommendations following the death of Lawrence Phillips, and at the request of the former Minister for Workplace Safety and Consumer Affairs, CBOS has engaged with jurisdictions around Australia to determine the status of legislation relating to chainsaw licencing and use. As part of this inquiry, CBOS also sought the provision of data relating to incidents of serious injury or death arising as a result of chainsaw use.
CBOS notes that other jurisdictions have accreditation or training requirements in place for those employed in forestry or related industries, as is the case in Tasmania. For example, Tasmania has adopted the Forest Safety Code of Practice (Tasmania). Training courses and accreditations are also available to consumers or traders through various educational institutions.
However, no other jurisdiction requires training or licensing for the private use of chainsaws, or accreditation for chainsaw vendors and retailers. Additionally, no other state or territory has indicated that they intend to regulate chainsaw use more broadly or strictly.
The authority to take compliance action and to regulate certain industries or practices is conferred on CBOS through relevant legislation. Under the current regulatory frameworks administered by CBOS, there are no licensing or accreditation requirements for private chainsaw use or retail sales. CBOS does oversee the licensing of occupational trades under the Occupational Licensing Act 2005, but not the use of products. CBOS is therefore unable to develop requirements or enforce compliance in response to concerns or recommendations regarding improper use of chainsaws by domestic consumers. Instead, CBOS ensures the products used are safe to operate, meet Australian Standards and are provided with consumer guarantees.
It should be noted that WorkSafe Tasmania also provides information on their website relating to chainsaw safety operating procedures and these documents are readily available to the public.

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.