An 85-year old Queensland aged care resident was found unconscious beside his wheelchair after being left outside for two hours in February 2023 on a 30 degree day, and died several days later in hospital.
Coroner Carol Lee, from the Queensland Coroner’s Court, found the man died from heat stroke, exacerbated by pre-existing medical conditions, including vascular dementia.
The man lived in the memory support unit of a residential aged care facility and was able to move freely around about the facility in a wheelchair. He was to be monitored hourly.
On the day of the incident, he had gone outside, where there was no shade and he was not easily visible, for two hours and 18 minutes.
When staff did locate the man, an ambulance was called and he was taken to hospital with burns. He died a week later in hospital.
Following the incident, the aged care facility made a number of changes including:
- Trained staff about the importance of hourly sighting to help monitor residents who wander
- Involved two employees per shift to share the responsibility of hourly sightings
- Equipped employees with arm bracelets to remind them of the hourly sighting responsibility
- Installed an alarm to alert staff if a resident leaves the building
- Removed a curtain to improve visibility to the outside area
The coroner said, “This tragedy was preventable and occurred in the context of staff failure to undertake periodic visual safety and wellbeing checks.”
After the inquiry, the residents’ wife expressed her gratitude to staff for the improvements the home made, and expressed her desire to continue visiting staff, to whom she had become close.
The staff member who failed to conduct the hourly check had their employment terminated.
