After investigating the unusual and tragic death of a 63-year-old man in a nursing home, a Victorian coroner has recommended the government legislate mandatory staff-to-resident ratios.
In her report into the death of John Reimers, Coroner Audrey Jamieson found he died in December 2018 after falling from his bed and trapping his head inside a drawer in his bedside cabinet.
The difficult decision to move into aged care
Mr Reimers suffered a stroke in 2014, which left him paralysed down one side. He used a motorised wheelchair to get around, and he suffered from shoulder pain and low mood.
In July 2015, it became difficult for Mr Reimers’ family to care for him, and he moved into a nursing home.
On the day he passed away, Mr Reimers woke early and got himself into his wheelchair.
The coroner said it appeared he had tried to open the bottom drawer of his bedside drawers, but in the process of leaning forward, had lost his balance and tumbled forwards.
Tragically, his head became lodged in the bottom drawer and he was unable to remove himself due to the weakness caused by the stroke.
Ambulance called within 10 minutes
Mr Reimers called out for help, and within 10 minutes of the fall an enrolled nurse (EN) was with him. When she saw how he was positioned, she asked for a lifting machine to be brought to the room and she dialled 000. She said she could not move him because he was lashing out.
Emergency services told the nurse not to move Mr Reimers and asked that someone wait out the front of the facility to help paramedics when they arrived. They also said someone should wait with Mr Reimers and to call back if his condition deteriorated.
While they waited for the ambulance to arrive, EN removed the wheelchair from the room, to remove obstacles, and checked Mr Reimers colour and for injuries. She told the inquiry she was concerned about moving him in case she injured him further. He continued moving and speaking while she was with him, and was able to give his date of birth, she said.
The EN waited out the front of the facility, while a personal care attendant (PCA) waited with Mr Reimers.
The PCA noticed Mr Reimers had become quiet and informed the EN, who then found his pulse was weak. The EN denied this occurred.
40-minute wait for ambulance
The ambulance arrived 40 minutes after the fall. Paramedics found Mr Reimers unresponsive and with his head in the drawer, and his neck bent over the edge. His airway was obstructed and he appeared blue in the face.
When asked how long Mr Reimers had been unconscious, the PCA said she thought he was only asleep.
The paramedics were easily able to remove Mr Reimers’ head from the drawer.
Paramedics discontinued CPR when advised an Advance Care Directive was in place that requested he not be resuscitated if found pulseless and not breathing.
Mr Reimers was declared deceased 45 minutes after his fall, and paramedics called police.
Mr Reimer’s autopsy report found he died from “complications of an inverted positional event”.
Confusion over Advance Care Directive
Catherine Reimers, Mr Reimers’ wife, told the inquiry she did not understand the ACD to mean her husband would not be resuscitated in the case of an accident.
Two staff for 34 residents, no RN on site
At the time of the accident, there was one EN and one PCA on duty to care for 34 residents.
The EN was employed through an agency, and did not inform the on-call registered nurse (RN) to tell him what was happening.
The RN told the coronial inquiry the agency nurse would have been given orientation at the nursing home of up to one hour.
He said, agency nurses “should already be trained and qualified to be able to attend aged care facilities to commence their shifts and to be fully capable of their duties.”
The EN on duty admitted she should have called the RN, and she regrets not doing so. She knew how to contact him, but had never met him.
Shift towards aged care as ‘homes’ not ‘hospitals’: expert opinion
Professor Debra Griffiths, Head of Nursing & Midwifery at Monash University provided an expert opinion to the inquiry. She said the more experienced staff member, the EN, should have remained with the resident. She said the PCA would not necessarily have had first-aid training, as it is not mandatory in the aged care industry or for Certificate III.
“Professor Griffiths associated diminishing requirements for staff qualifications in the aged care sector with a shift in thinking about what is being provided to residents of these facilities, the facilities are ‘homes’ or ‘alternative homes’ rather than hospitals,” the coroner wrote.
“Professor Griffiths informed me that this has also had the effect of minimising operational costs, which appears to be the primary impetus for the shift,” the coroner said.
Professor Griffiths said an RN should always be on duty in an aged care facility, though she conceded an EN and a PCA may be capable of staffing a nursing home overnight so long as residents are low care and if backup can be called upon.
She said Mr Reimer’s ACD appeared to reflect his rights accurately, but she said there is a danger their rights can be taken out of context. For example, a ‘not for resuscitation order’ does not apply across the board. Say, if a person falls and loses consciousness, it would not be appropriate not to apply any treatment, Professor Griffiths said.
The EN should have applied more first aid before the paramedics arrived, Professor Griffiths said, and should have made more of an effort to remove Mr Reimers from the drawer and to provide care to him.
Ambulance misidentified “bizarre accident”
The person who took the 000 call identified the matter as a fall, however, prompter attention would have been received if it had been identified as ‘inaccessible incident / other entrapment’.
The coroner conceded Mr Reimer’s death was the result of a “bizarre accident”.
The coroner said “this scenario is unlikely to have arisen if there had been an RN on site”. She said the situation was “beyond (the EN’s) capabilities” and was left to someone without even first-aid training.
Staff-to-resident ratios should be mandated: coroner recommends
Ms Jamieson recommended the nursing home always ensures an RN is on site or, at least, reasonably close by.
She recommended the nursing home train staff in how to escalate incidents, including when to contact the RN for help.
She recommended that government, regulators and operators develop national standards for staffing levels and skill mixes in aged care, and to legislate minimum staff-to-resident ratios.
She recommended that governments make it mandatory for personal care staff to hold first-aid qualifications before they can work in aged care.
The coroner recommended that the nursing home provide clarity around when resuscitation is required, including making a distinction between resuscitation after “natural or unnatural events”.
This tragic incident reveals so much about the aged care system in Australia, from low staff numbers to poor training and lack of regulation.