Betty Quayle was 89 years of aged when she died on 31 May 2013.  Mrs Quayle resided at an aged care residential facility in Cairns.

Resident A also resided at the same aged care residential facility.  Resident A was 74 years old and suffered from cognitive impairment, consistent with alcohol related dementia.

At about 3:00am on 30 May 2013, Resident A wandered from his wing and inadvertently into Mrs Quayle’s room. Resident A, believing he was in his room, told Mrs Quayle to wake up and get out of his bed. Mrs Quayle was unable to respond to him. Resident A then attempted to remove her from the bed. He assaulted Mrs Quayle a number of times causing a number of visible injuries to her, before leaving the room.

The pathologist determined that the medical cause of Mrs Quayle’s death was blunt force trauma.

Resident A had a long history of difficult and violent behaviours, including absconding, verbal and physical aggression towards staff and residents and intoxication prior to Mrs Quayle’s death.  

Notwithstanding these behaviours, Resident A was transferred to a non-secure unit within the aged care residential facility on the recommendation of his GP.

In reviewing the actions taken by the aged care facility, the Coroner noted that many of the care strategies employed were focused on Resident A and did not consider safety strategies with respect to other residents.  The Coroner found that it was the responsibility of the aged care facility to properly weigh the GP’s recommendation against the safety, welfare and particular vulnerabilities of the other residents.

The Coroner also found that the safety and welfare of all residents at the facility was paramount against the background of known risk of violent and aggressive behaviours exhibited by Resident A.

The Coroner was also scathing about the failure of the then Australian Aged Care Standards and Accreditation Agency to investigate, examine or analyse Ms Quayle’s death and their ultimate finding that there were no systemic issues at the facility.

With providers increasingly encouraged to support the dignity of risk for individual consumers, this decision comes as a timely reminder for providers to also weigh consumer preferences against the safety and welfare of other residents in their care.

To read the Coroner’s findings, click here.