A coroner has found staffing and medical response deficiencies were present in the circumstances surrounding the death of a patient at a state run mental health rehabilitation facility.
Kenneth Francis Dunster died due to asphyxiation as the result of choking on food at Millbrook Rise Centre in New Norfolk on July 1, 2015.
At the time of the incident Mr Dunster was being supervised by two staff members, as the third had gone home on their lunch break.
Coroner Simon Cooper said on the day of Mr Dunster’s death the level of supervision afforded to him, and for that matter other residents, was lower than was necessary to ensure the safety of the patients on the ward.
Mr Cooper said the medical response to Mr Dunster’s collapse “may have been improved.”
Mr Cooper said there was some confusion among staff in relation to the nature of the “code” that was called as there was a perception that it did not matter whether a code blue or code black was called.
“With respect I cannot agree that the nature of the emergency did not matter,” Mr Cooper said.
“A medical emergency calls for a completely different response than the threat or actuality of an assault or an attack upon staff or another patient.”
“Medical response equipment, oxygen, defibrillator and like, will be needed to be taken to a medical emergency but is completely unnecessary at a code black.”
Various changes have been made at Millbrook Rise since Mr Dunster’s death including the introduction of enhanced dental services, ensuring maximum numbers of staff are able to supervise meals and the focus on first-aid response to choking deaths.
Mr Cooper said in relation to these changes made at the centre he will not make any additional comments or recommendations.
The Department of Health was contacted for comment.