The death of an 89-year-old woman who was assaulted by another resident with a history of violence in a Cairns aged-care facility could have been prevented, a Queensland coroner has found.
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Betty Quayle died in hospital on May 31, 2013, the day after a 74-year-old man assaulted her in the middle of the night in her bed at the Glenmead Village in Cairns.
In findings handed down earlier this month, northern coroner Nerida Wilson criticised the response of the national aged-care accreditation agency, which in an audit conducted a month after Mrs Quayle's death "essentially concluded that there were no systemic issues".
The woman’s death was not “investigated, examined or analysed” by the agency, and the facility’s owners did not acknowledge any “systems or procedural failures”, she said in her non-inquest findings.
In May 2013, Mrs Quayle was a resident at Glenmead Village, then owned by Blue Care Queensland. The aged-care facility was sold to Regis Aged Care in 2015.
The 89-year-old was in her bed about 3am on May 30, when another resident – who had a history of aggression and violence – entered her room.
The man, referred to only as Resident A in the coroner’s report, had symptoms of alcohol-related dementia and was later charged with manslaughter but found by the Mental Health Court to have been of unsound mind at the time of the death. The charge was dropped.
The 76-year-old, thinking he was in his own room, demanded Mrs Quayle leave. She was “unable to respond”, the coroner said, and the man tried to move her, then assaulted her, possibly with a pillow.
The coroner noted Mrs Quayle was "particularly vulnerable to injury from minimal force".
A nurse saw the man with blood on his hands and clothes, before leading her back to Mrs Quayle’s room, where she was discovered seriously injured.
Mrs Quayle died in Cairns Base Hospital the next day.
The 76-year-old had been admitted to Glenmead Village in May 2011.
Between June 2011 and May 2013 he had an extensive history of aggression and violence.
Blue Care Queensland’s file notes said he “definitely needed dementia secure accommodation” and would become “very upset and aggressive if he does not get what he wants”.
The man was admitted to a secure unit at Glenmead Village in 2011 but four months later his doctor suggested he be moved to a non-secure lodge to better manage his frustration.
“Six days after he struck another resident … Resident A was moved to the non-secure unit,” the coroner’s report noted.
After being moved, Resident A repeatedly went wandering and came back intoxicated.
Following the assault on Mrs Quayle, police charged the attacker with unlawfully doing grievous bodily harm. After her death, the charge was upgraded to manslaughter.
In June 2016, the Mental Health Court found he was of unsound mind at the time of the death, and the charges were dropped.
Blue Care Queensland told the coroner the organisation believed Resident A’s behaviour was being managed adequately and it was “wholly unexpected” he would assault another resident.
Glenmead Village passed three audits in March 2013, September 2013, and September 2014.
The Australian Aged Care Quality Agency, now known as the Australian Aged Care Quality Agency, assessed the facility in July 2013, following Mrs Quayle’s death, and found the facility “met the expected outcomes” for behavioural, physical environment and safety management.
The agency concluded Glenmead’s environment was monitored, problems were identified and it managed to ensure safety.
“I note these observations were made within five weeks of Resident A wandering without impediment into Mrs Quayle’s room at approximately 3am,” the coroner said.
In July 2013 the federal health department told Glenmead Village no further action would be taken following Mrs Quayle’s death as it was “satisfied … reasonable actions had been taken”.
Coroner Wilson noted a response from the aged-care standards agency to her draft findings in which the organisation disagreed it was responsible for investigating Mrs Quayle’s death.
The coroner questioned why Mrs Quayle’s death was not mentioned in the report, and said the agency’s response was “inadequate”.
“I find this failure all the more egregious given the draft findings gave a clear account of Resident A’s behaviours in the almost two years prior to March 2013,” she said.
The agency agreed it would have been “preferable” to mention her death in the July 2013 report.
Blue Care Queensland said it had no alternative options for housing the attacker, and did not expect his behaviour could lead to another person’s death.
Mrs Quayle’s adult children told the coroner they were concerned that while Blue Care Queensland had taken “remedial action” since their mother’s death, “any systems failing prior to her death were neither owned or acknowledged”.
“I find that if Glenmead Village had adequately managed the risk of harm posed by Resident A, Mrs Quayle’s death could have been prevented,” the coroner concluded.
The coroner referred the incident to the Aged Care Quality and Safety Commission and directed a copy of her report to the Royal Commission into Aged Care Quality and Safety.
