Council of the ageing is calling on the aged care industry to take note of Coroner Rod Chandler’s findings into the death of a 92-year-old man.
A report released on Tuesday found Alan John McKenzie died from heart failure aggravated by injuries sustained when falling from a chair that has since been deemed not fit for use.
Coroner Chandler recommended the Fred French Nursing Home at Newstead review protocols around the regular inspection, maintenance and repair of equipment and its fault-reporting procedures.
COTA chief executive Sue Leitch said the findings points to the need for robust systems in residential aged care and also with the care-at-home providers so systems can keep older people safe and care meets their needs.
Mr McKenzie, a sufferer of chronic obstructive airways disease, Alzheimer’s Disease and dementia, became a resident of the home in June 2017.
By November, Mr McKenzie was unable to stand or walk without assistance so he was given a princess chair to help him move around.
Mr McKenzie fell head first from a princess chair after leaning on its armrest while watching TV with other residents on April 14, 2018. He died at 5.45am on April 15.
McLean Healthcare technician Aaron Dilllon examined the princess chair at the request of Tasmania Police.
He found the rear brake was not working, the right armrest was difficult to release because of a stripped thread and the spring mechanism was worn and not properly lubricated, the right armrest also didn’t lock into the upright position properly and the left leg was missing a bolt.
“It was Mr Dillon’s opinion that the chair should have been removed from use until fully repaired,” the report said.
Coroner Chandler said the evidence made it apparent that the princess chair was not fit for use and should have been removed prior to Mr McKenzie’s fall.
“The fact that it was not removed from use demonstrates very serious shortcomings in the home’s systems concerning the regular inspection of equipment, the reporting of faults and the carrying out of repairs,” he said.
“I am satisfied that Mr McKenzie’s premature death was a direct consequence of the right armrest to his princess chair collapsing when he leaned on it causing him to fall to the floor.”
Ms Leitch said people should be able to raise concerns about the provision of care with their providers and for them to be resolved promptly.
If concerns are not addressed, people can call the Aged Care Quality and Safety Commission on 1800 951 822.