A 92-year-old South Australian woman who sustained a savage attack by another resident in the aged care home where she lived, was “unable to escape” and her carers exercised a “gross dereliction of proper management”, the Coroner has found.

The South Australian Coroner Mark Johns handed down his findings into the 2012 death of Dorothy Mavis Baum in an Adelaide nursing home.

Ms Baum, who was 92 at the time, was beaten with a plastic chain by another resident, Rozalia Setalo, who was 85 and was living with dementia.

Ms Baum was left lying in bloody sheet for two hours before being attended to. She died the following day from her injuries.

Mr Johns found that the two nurses in attendance at the time of the incident exercised a “gross dereliction” in their care of Ms Baum.

Registered nurse Ute Latz and carer Harit Kamal barricaded themselves in the nurses’ station during the attack, and did not deal with Ms Setalo, because of the risk they believed it would expose them to.

But Mr Johns said that both the nurse and the carer were “duty bound” to take on some risk during the incident because if they didn’t, residents, who were relatively much more vulnerable, could be injured.

When Ms Baum was finally discovered after the attack, Mr Johns said she was not sent to hospital quickly enough.

Mr Johns also said that Ms Latz and Mr Kamal delayed a proper investigation into the incident by suggesting that Ms Baum had inflicted the injuries on herself.

Mr Johns said the fact that those who were managing the nursing home at the time of the attack escaped sanction was “entirely inadequate”.

Operational changes introduced to the Commonwealth Aged Care Framework in 2018 would mean senor management and nursing home boards would have to be more accountable, the Coroner said.

“Only by adopting a scheme in which there is some personal risk to those involved in the management of aged care providers at the highest level could the public be confident that an event such as the appalling treatment of Mrs Baum in life and then in death could not happen again.”

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