Coronial Findings 2023

Response received by State Growth on 30 October 2024.

The department has completed a corridor study for the East Tamar Highway, which has identified and prioritised improvement opportunities along the highway. The corridor study is due for publication later this year.
Upgrading and improving the safety of the East Tamar Highway/University Way intersection has been identified as a high priority in the corridor study.
The department has identified possible improvement options for this intersection in the planning work, including a roundabout or signalising the intersection. The options will further be assessed as part of the design process, which is planned to start later this year.
The design process will include traffic modelling of the different options, public consultation, and selection of the preferred option. In terms of timeframes, a typical design period for this type of project is about two years. Based on this, construction of safety improvement could likely occur in the 2026-27 financial year.
While noting they were not related to the subject crash, previous road safety interventions implemented at this intersection include:
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Extending the right turn deceleration lane on the East Tamar Highway in 2013-14 to reduce the likelihood of rear-end type crashes.
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Banning the right turn movement from University Way to the East Tamar Highway in 2016, which was the highest safety risk involving right turn movements at this location and had resulted in a disproportionate number of serious injury crashes for the very low number of drivers making the right turn to the north.
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The speed limit being lowered to 80km/h from the original 100km/h just north of the intersection. It is also noted that drivers turning right into University Way from East Tamar Highway have an unobstructed forward view to this slower approaching southbound vehicles and only need to select a gap in this one lane of oncoming traffic.

The department has been monitoring the safety performance of the intersection and there have been no other reported crashes involving the right turn movement from East Tamar Highway and University Way since the subject crash.

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 provided by Deputy Secretary - Clinical Quality, Regulation and Accreditation received 25 October 2024

For some time, it has been a requirement by the Department of Health that a summary of the patient’s care including medication changes (separation summary) is provided to the nominated GP for every admission at the time of discharge or if not possible within forty-eight hours of discharge. The timeliness of this information is audited. This information was not previously routinely seen by pharmacists.    
Improvements since this case in 2020, include changes to the computer systems that are used by medical staff to prepare and transmit discharge summaries.  These include:

*All Discharge summaries now go to My HealthRecord (MyHR), provided the patient has not opted out.  A community pharmacist can routinely look at any patient’s uploaded discharge
summaries.  Whilst this functionality existed in 2020, it was less common for pharmacies to use MyHR to review patient information.
*Since November 2021 a curated “Pharmacist Shared Medication List (PSML)” is issued for a patient at the THS.   PSMLs are automatically transmitted to MyHR, provided the patient has consented to their information being uploaded.  This list can be used by community pharmacies to understand patients’ hospital medication management.

Since patients do not typically have one-to-one relationships with their community pharmacy it is not possible to send discharge summaries routinely to specific pharmacies (unless advised by the
patient). However, all community pharmacies can now retrieve information from the MyHR.  
All medication changes made in the hospital are considered critical given they typically relate to safety or efficacy and are reflected in the Discharge Summary.

Response received from Department of Health 24 January 2025

Coroner’s Recommendation (paragraph 79): I recommend the RCA’s recommendations set out in paragraph 54 are implemented in full.

* The Mental Health Hospital in the Home (MHHITH) documentation requires completion and endorsement within the next 3 months, and it is to be made widely available. Response The MHHITH Operational Service Manual (OSM) has been completed and is operational. Documents are available to all staff in the Strategic Document Management System from where all Department of Health policies and protocols are accessed by staff.

* Entry into the record must reflect what service is being provided rather than an individual consultant’s name. Response: Naming conventions are in place for all teams and services, and clinical entries clearly identify the clinician and clinician’s service unit.

* The orientation program of MHHITH is to provide a comprehensive education session of the Digital Medical Record (DMR) documentation processes. Response: Education and introduction to the DMR occurs as part of orientation for staff within all areas within SMHS (including MHHITH). Regular monitoring of the health records occurs within the service.

* The MHHITH services admission criteria are to be revised to provide greater guidance on admission suitability for clients who have made recent self-harm and/or suicide attempts

Response: The clinical needs of all individuals referred to the MHHITH and individuals within their care are discussed twice daily at multi-disciplinary team meetings. Changes to admission status, including admission to the inpatient units, can occur through direct discussion with senior clinicians, including out-of-hours through the Acute Care Stream umbrella.

* MHHITH is to consider access and availability for psychological intervention where it is clinically indicated, and it is either to provide those interventions or to refer patients to services that can provide that treatment. Response: MHHITH have access to the multidisciplinary team including social work, occupational therapist, medical staff and senior nursing staff all of whom have received training in therapeutic approaches including ACT, DBT CBT. Access and referral to other services is undertaken, as required.

* Where consent is provided MHHITH is to ensure the involvement of significant others in the provision of collateral information. Response: At admission, MHHITH collects and documents information about family/carers and other service providers. Consent for exchange of information is obtained at the beginning of an episode of care. The General Practitioner is informed at the commencement and closure of an episode of care. The introduction of the Carer’s Recognition Policy with associated action supports inclusion of significant others in the collection of information and care provision.

Coroner’s Recommendation (paragraph 80): I recommend that in order for mental health patients to build trust and rapport with their treatment providers that the number of medical and allied staff be limited to as few staff as possible in order to avoid the difficulties highlighted in paragraph 46. Response: Statewide Mental Health Services strive at all times to provide continuity of care for mental health patients. To ensure the provision of appropriate care 24 hours per day, 7 days per week. MHHITH has good handover and communication processes in place. Twice daily reviews also ensure that care and support provision is adjusted continuously.

Coroner’s Recommendation (paragraph 81): I recommend the responses to Coroner McTaggart’s recommendations set out in paragraph 58 are finalised as soon as reasonably possible. Coroner McTaggart’s recommendations.

I. The design and establishment of a dedicated inpatient unit for adolescents or young persons between the ages of 12 and 25 years, including treatment for those suffering from an acute state of mental illness or suicidality.

II. Consideration be given to the establishment of a multi-disciplinary facility for young person’s suffering from an acute state of mental illness or suicidality, such facility to have a comprehensive through-care and after-care model to provide ongoing community–based risk management.

III. The establishment of state-wide positions of suicide prevention co-ordinators to provide necessary outreach between discharge from hospital and entry into appropriate services to assist with a streamlined approach to discharge planning, collaboration between service providers and continuity of care;

IV. Hospitals offering emergency medicine consider developing and implementing a suicide risk assessment tool, to be applied consistently on a state-wide basis where suicidal risk assessment is required.

Response

i) The recent redevelopment of the RHH included a new 16 bed adolescent inpatient unit which is managed through the Paediatric Ward with 2 Mental Health beds. This unit opened in 2020 and delivers an integrated model of care whereby mental health patients and paediatric, medical, and surgical patients are supported in the one unit. Stage 3 of the RHH Site Masterplan Review 2020-2050 recommended the redevelopment of the St Johns Park site as a campus of the RHH.

ii) Funds have been allocated to project manage, create and staff an adolescent and youth Inpatient unit.

iii) The Government’s response to the Commission of Inquiry into Sexual Abuse in Institutional Settings included funding the creation of an adolescent-youth inpatient mental health facility for Tasmania. In the 2024 Budget, there was a significant increase in funding for CYMHS's out-of-home care program and CYMHS youth forensic program. Augmented funding will assist with interventions aimed at addressing the high-rate suicide in these groups. The service will be integrated with CAMHS community and hospital-based services. The Government commissioned two Safe Havens. The first Safe Haven opened in North Hobart in 2022. A second Safe Haven will have a more youth/young adult focus and is part of the Northern precinct build planned for 2027. An additional build will occur in Devonport in cooperation with Primary Health Tasmania. Both services will include in-reach from the CAMHS Youth Mental Health Team in the form of consultation and provision of a group intervention to assist with management of emotional wellbeing. A new CYMHS campus has been established and is running in Devonport.

iv) To assist people in hospitals experiencing suicidality, rather than creating suicide coordinators, a more robust approach to suicide prevention is proactive follow-up. This is in place for all CYMHS consumers. Consistent with this, a new seven-day postdischarge clinic has been established in the South; young people experiencing suicidality are proactively followed up, monitored, and reviewed prior to service allocation and entry. A similar undertaking is planned for the North and North-West.

v) To assist with suicide risk assessment, a Comprehensive Care Plan is now in place across SMHS and includes individualised risk assessments that inform care plans, safety plans and relapse plans.

Response from  WorkSafe received 12 March 2024.

Under the Work Health and Safety Act 2012, persons conducting a business or undertaking (PCBUs) are responsible for inspecting and maintaining tractors to ensure they are safe to use.
As noted in Coroner McTaggart’s report, in 1982 legislation was introduced to mandate the use of roll-over protection for tractors. A tractor must not be used in a workplace unless it is securely fitted with a roll-over protective structure (ROPS). This does not apply to a tractor under 560kg or over 15,000kg, a tractor installed in a fixed position and incapable of moving, or a tractor used for a historical purpose or activity. If the tractor is used where it is too low for the tractor to work with the ROPS in place, then the ROPS may be lowered or removed only for this situation and only if other measures to reduce the risk of roll-over are in place. ROPS must comply with the relevant Australian Standard.
If a tractor was manufactured prior to 1982 and does not have a ROPS, it must be fitted with one before being used in a workplace.
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While consideration has been given to the prohibition of tractors manufactured before 1982, feedback from the rural industry is that this is not supported, and will bring significant cost to affected businesses, many of which are small, family-based operations.
Alternatively, tractors can be fitted with a variety of other attachments and implements designed for specific purposes, including a STAP. However, each particular attachment that is fitted to a tractor introduces a new set of hazards, even if the tractor itself is set up for safe use. Planning and selecting the correct equipment for the intended task and terrain is an important step in managing risks. The use of a STAP may in some instances create a higher risk for the user of the tractor than if one was not fitted. This is particularly the case where the STAP was not designed specifically for the tractor that it is fitted to.
Since the release of Coroner McTaggart’s findings, WorkSafe Tasmania has implemented a number of initiatives aimed at improving awareness of the risks associated with tractors on farms and educating businesses on how to reduce these risks. The Safe Farming Tasmania (SFT) program was launched in 2014. The SFT program was designed to raise awareness of farm safety issues state-wide. The SFT program is a joint initiative between WorkSafe Tasmania and the Department of Natural Resources and Environment, and has been modelled on WorkSafe Tasmania’s existing Work Health and Safety Advisory Service.
The SFT program was developed in consultation with the rural industry, and is strongly supported by an industry-led stakeholder reference group. This work is gaining national attention for its approach to raising awareness of work health and safety in the rural sector.
The SFT program aims to reduce farm related death, injury and disease, and improve the health and safety of workers in the Tasmanian rural sector by:
* raising awareness of farm safety issues;
* encouraging discussions about safe farming;
* building leadership safety cultures and influencing attitudes;
* producing and disseminating targeted information; and
* working with industry stakeholders to provide training and education.
In the financial year to 30 June 2023, the SFT Program provided over 200 requests for guidance and advice. SFT is also collaborating with business partners to run a series of tractor safety awareness sessions throughout the State including King and Flinders Islands. Plans are well underway for this to occur.
Since the inception of the program to the end of March 2023, over 315 safety management plans have been developed for and with farmers, tailored to their individual farm operations. These safety management plans are critical to achieving safer farming practices and outcomes.
In addition to the SFT Program, the Government offered a Primary Producer Safety Rebate Scheme (the Scheme), which opened on 1 October 2021 and closed on Thursday, 30 June 2022. The Scheme provided a rebate of up to $5,000 for the purchase of workplace safety solutions to medium, small and owner operator businesses within the agriculture sector in Tasmania.To ensure that the rebate scheme had the greatest impact on our farmers’ safety, it covered eligible items that mitigate the risk of injury caused by the five major causes of injury or death in farming:
* body stressing;
* falls, trips and slips of a person;
* being hit by moving objects;
* hitting objects with a part of the body; and
* vehicle incidents.
To address quad bike and tractor (vehicle) incidents, helmets and training were included for applicants who own a quad bike, side-by-side vehicle, or tractor for work purposes.
The scheme guidelines were developed in consultation with the industry-led Safe Farming Reference Group. They covered a wide range of commercially available safety measures including, in the cases of vehicles, agricultural side-by-side vehicles, ATV operator protection devices such as quadbar, helmets, and, for tractors only, rollover protection structures and run over protection devices. In total 786 applications were approved under the Scheme, paying out more than $3.6 million in rebates to primary producers.

Response provided by Southern Cross Care  10 October 2024

SCC provides the following detail:
Recommendation 1: That the Fairway Rise nursing home takes appropriate action to ensure, to the extent possible, that residents who are assessed as requiring hip protectors are fitted with them at all times when required.
Response:
Since this incident, Fairway Rise has implemented continuous improvement activity to ensure that, to the extent possible, all residents who are assessed as requiring hip protectors are fitted with them at all times (Attachment 1).
In summary, these actions include:
▪ audit of all residents at the home to identify those requiring hip protectors vs available protectors
▪ purchase of additional stock where required
▪ improved documentation on resident care plans about need for hip protectors, where they are stored, and how to access additional equipment if required
The incident, and Coroners recommendations have been shared with all SCC homes through the Clinical Committee.
To ensure that residents requiring hip protectors are identified, the home has implemented a local falls committee group, for ongoing and identification and review of frequent fallers and those at high risk of falls and falls with injury. Regional (North and South) falls committees have been formed, led by the Quality Team. Information from falls committees at the local level feeds into these regional
committees, to ensure that learnings from falls are shared and initiatives to reduce the risk of falls and falls with injury are implemented.
In reviewing the recommendations and actions implemented, SCC does note, that there is not a requirement under the Quality of Care Principles 2014 to provide hip protectors for residents (Attachment 2 – p 56 - 60). While, as a result of this incident, the home purchased and provided hip protectors, on an ongoing action, the home communicates with the resident and/or their nominees to gain consent for purchase of hip protectors as an out-of-pocket expense on the resident’s behalf. Where the resident/nominee declines to incur this cost, this will be documented in the risk assessment.
It is noted that evidence on the effectiveness of hip protectors to reduce hip fractures is mixed.
Farrell and Walter (2021) conducted a review of evidence-based literature and referenced three key guidelines in the use of hip protectors. Essentially, indicating that there was mixed evidence of effectiveness and recommendations for use and that these recommendations were also impacted by compliance with wearing hip protectors.
The Royal Australian College of General Practitioners published guidelines in March 2024 that identified there was moderate-quality evidence for a small reduction in hip fracture risk when hip protectors were implemented for residents in residential aged care facilities. This was an update to the previous guidelines from 2017 which recommended ‘use of hip protectors should be judicious, as it is not possible to abolish the risk of falls and fracture in most elderly people. It should be noted that hip protectors do no work when not used. Compliance is crucial.’ (Royal Australian College of General Practitioners, 2017 p: 63).
Consequently, SCC remains committed to comprehensive falls risk assessment and the implementation of a range of person-centred care strategies to reduce the risk of falls and the risk of injury from falls. These strategies will include consideration of the appropriateness of use of hip protectors, and enablement, to the extent possible, that residents who are assessed as requiring hip protectors are fitted with them at all times when required.

Attachments 1 & 2: Not published to web

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 provided by Regis Aged Care 2 October 2024.

Falls Prevention and Management at Regis Pty Ltd:

Regis Pty Ltd has a comprehensive falls prevention and management framework in place that supports the proactive identification of each residents falls risk.
The process of falls risk assessments commences upon request for the resident to be admitted to the Service. This pre-admission clinical review is completed to ascertain if the Service is able to support a potential resident including environment and equipment that may be required.
If the resident is identified as a high falls risk prior to admission a care planning consultation with the potential resident and next of kin will be conducted to identify mitigation strategies and consider dignity of risk.
On admission day, any assessed supports or services that have been identified will be implemented including falls sensors/floor mats/bed or chair sensors. These support needs are reviewed by allied health professionals (Physiotherapy) within the first two (2) days of the resident’s arrival within the Service.
On day one the Falls Risk Assessment (FRAT) is formally documented within Autumn Care. Reassessment of a resident’s falls risk is undertaken quarterly as part of the Care and Wellbeing review (involving the GP and Allied Health team), following an actual or near miss fall, changes in the resident’s clinical condition or preferences expressed via resident.

Use of Sensor Alarms in falls prevention and management:

Sensor alarms are available for all residents assessed as requiring the support. The decision to implement a sensor alarm is informed by the following factors:
* Falls history including frequency and mechanism of fall
* Changes in clinical condition
* Resident’s insight into their physical abilities and need to wait for staff to assist them to mobilise/transfer
* Resident/representative’s request
* Expressed fear from resident/representative of a fear of falling
* Allied health review and recommendation
* Residents’ sensory deficits that may impact an independent resident in some circumstances e.g. resident with visual deficit that gets up during the night to go to the bathroom.

There is a defined process within each Service to ensure that there is always adequate stores of sensor alarms. This process is monitored by the clinical care team.

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.