Coroner: shortage of care assistants led to Black Saturday death

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Coroner: shortage of care assistants led to Black Saturday death

A reduction in care assistant numbers at a Melbourne nursing home on Black Saturday in 2009 contributed to the death of an elderly woman from heat stroke, a coroner has found.

On the afternoon of February 7 2009, Joan Ambrose, 79, a patient at the Noble Manor Nursing Home, who suffered dementia and had heart problems, is understood to have walked unobserved to an outside courtyard of the home, and become trapped outside. With the door only designed to open outwards, she was unable to return without getting someone’s attention inside.

The inquest heard Mrs Ambrose went outside shortly after 1.05pm, as the temperature soared past 46 degrees, but wasn’t discovered to be missing until three hours later.

The patient’s body was found just after 4pm in the courtyard, where the hot bricks and paving would have boosted the temperature even higher than the maximum 46.4 degrees recorded in Melbourne that afternoon, the inquest heard.

Only two personal care assistants were on duty from 1pm to 3pm, with the home having begun trialling a reduction in staff levels that day.

Coroner Peter White found Mrs Ambrose died from a combination of ischaemic heart disease and heat exposure. He stated that staff reductions had led to a situation in which a frail woman had been left to wander outside despite warnings that the elderly would be particularly vulnerable to the day's heat.

"I find that given the anticipated conditions, about which Noble Manor had adequate prior warning, management failed to make appropriate plans to protect Mrs Ambrose and that this failure contributed to her death," Mr White said.

He added that in future the Aged Care Standards and Accreditation Agency should require that aged care facilities strictly control their entry/exit points as part of their extreme heat emergency management plans.