The death of a Queensland aged care resident who was left alone in direct sun as temperatures reached 30 degrees was a preventable “tragedy”, a coroner has found.

In published coronial findings, it was revealed the 85-year-old man was found unconscious on the ground beside his wheelchair at a regional Queensland facility in February last year.

It was determined he was in the unshaded garden for more than two hours and had suffered serious “environmental exposure”.

Paramedics who attended the facility attempted to cool him with ice packs and wet towels before he was taken to hospital.

Heat stroke cause of death

He was treated for significant hyperthermia and severe blistering and burns to his wrist and lower leg. He died several days later in hospital. 

A forensic pathologist found the cause of death was heat stroke, exacerbated by other pre-existing medical conditions including Alzheimer’s and vascular dementia.

An investigation at the facility after his death found the resident, who also had a history of falls, had “a very determined manner” and was “not easily distracted from an activity that he wished to pursue”.

The investigation found “most of the time the resident would do what he chose to do” and this was respected by the staff.

His wife, who did not live at the facility, agreed it was “reasonable to support” his preferred movement and choices for his daily activities as this “engendered his purpose of life”.

To facilitate this, she approved a plan of care with the facility which included an “hourly sight charting”.

This meant he was supposed to be physically observed by an assistant in nursing every 60 minutes to confirm he was safe and well.

However, on that day the man was not seen between just before 10am and about 12:20pm, the investigation found.

He was discovered by a registered nurse who began searching for him after she was unable to find him for his scheduled midday medication.

Staff member terminated

Coroner Carol Lee said in her findings “this tragedy was preventable”.

“[The death] occurred in the context of staff failure to undertake periodic visual safety and wellbeing checks,” she said.

Coroner Lee found the facility had been the subject of a comprehensive investigation by the aged care regulator and there had been significant actions taken since to improve safety.

“[I] am satisfied that the combined effect of these strategies will prevent a similar incident from occurring again in the future,” she said.

“The staff member who failed to undertake the critical sight observations has been terminated and has been the subject of a mandatory report to the Office of the Health Ombudsman.”

Facility identifies ‘gaps in care’

Since the death, the facility had identified “gaps in care” and provided further education to staff on the “importance and reinforcement” of completing sighting charts.

The facility has also changed the process with relation to “wandering residents” to a “two-person authentication process” by assigning a second assistant in nursing to ensure sightings are completed.

An alarm has also been installed on the doors to the garden and staff are alerted when a resident leaves the building.