The care received by Aubrey Reeve, resident of Umina Park Home for the Aged, leading up to his death on 24 July 2023 was "not of an acceptable standard" and "likely contributed" to the fall that caused his death, said the Coroner of the Magistrate's Court of Tasmania, Simon Cooper, in December last year.
The Coroner found that movement detectors in Aubrey's room were not operating properly, which may have meant staff did not assist him when he fell from his bed.
"It is essential that Residential Aged Care Facilities ensure that movement detectors, in addition to being fitted and appropriately installed as and when required, actually operate correctly," the Coroner wrote.
The Coroner also noted inadequate records about checks on Aubrey, as well as a lack of progress notes, fall assessments, and care plans.
Though Aubrey was considered a high falls risk due to falling increasingly often in the last year of his life, a falls plan was not provided to investigators.
However, the Coroner said the provider had taken efforts to improve its services since the incident.
"I acknowledge the steps taken by the Residential Aged Care Facility to attempt to ensure mechanical deficiencies in relation to movement detectors and similar are identified and rectified by staff in a timely manner. I also note the various measures taken by Umina Park to enhance overall quality of care since Mr Reeves fall," he wrote.
“On behalf of OneCare, I offer my condolences to the family of Mr Reeve and sincerely apologise to them, along with our other residents and families, for failing to meet the very high standards we expect for our aged care facilities," said Peter Williams, CEO of OneCare, the operator of Umina Park.
He told The SOURCE that OneCare has already put in place procedures to ensure fall-detecting equipment is functioning properly and alerting staff if a fall occurs.
“As an organisation we strive to provide the highest quality of care each and every day, and it is extremely regrettable that we failed to deliver on that commitment. We do not take that lightly and have a responsibility to make sure we do better," he said.
A review by the Aged Care Quality and Safety Commission in March 2023 found the home failed to comply with the Standards for services and supports for daily living, feedback and complaints, and organisational governance. An assessment in December found the home "compliant" in the three standards previously not met.
