An inquest has announced its findings into the case of a 90-year-old woman who was found by staff with a head injury under an ornamental antique car in the courtyard of an aged care facility in Ainslie.
Ruth Allison McKay, who had advanced dementia and was known to wander, entered the courtyard of Goodwin House, the Ainslie aged care home where she lived, undetected in the early hours of 17 January 2015.
In the ACT Coroner’s Court, Louise Taylor’s published findings for the inquest found the mother of three had been outside for two to three hours before she was found by staff and taken to Canberra Hospital. She died six days later from a bacterial infection, acute bronchopneumonia, a type of pneumonia that causes inflammation in the alveoli.
Coroner Taylor noted Mrs McKay’s pre-existing medical conditions, including her Alzheimer’s, made her more vulnerable to infection.
She found Mrs McKay had received “appropriate treatment and care” at Canberra Hospital in the days following the incident.
However, Coroner Taylor also found it was “highly likely” Mrs McKay’s absence from her room or presence in the courtyard could have been detected sooner “if there had been an alert or alarm system on corridor doors … and/or if sensor mats had been operational in [her] room”.
Mrs McKay’s care plan prescribed room sensors to mitigate the risk of her wandering, but they were not operational at the time of the incident.
The court heard from family members of two other residents who reported sensor mats were often not switched on and also heard a review conducted by Goodwin revealed all the sensors were working, leading Coroner Taylor to infer the use of the mats was “burdensome” for staff as they sounded an alert every time a movement off the bed was recorded, even when there was no risk to the resident such as use of the bathroom.
Coroner Taylor found the busyness of the shift and security of the corridor door also contributed to Mrs McKay accessing the courtyard undetected.
The court heard that although the corridor doors were locked each night, they could be easily internally unlocked without any alarm going off.
“There was no evidence before me upon which I could conclude that the task … was physically beyond Mrs McKay,” Coroner Taylor said.
“I am satisfied that this is precisely what she did to access the courtyard where she was ultimately found on 17 January 2015.”
The court heard of two other incidents where residents exited the facility at night and had difficulty coming back inside prior to Mrs McKay’s death.
Coroner Taylor found the failure to ensure residents could not go outside led to Mrs McKay’s death, but she did not make any recommendations.
“I am satisfied Goodwin rectified this situation entirely … with the installation of a timed automatic door, locks and ultimately CCTV,” she said.
But Coroner Taylor said it was “surprising” the risk posed by the corridor doors was not identified during the 2012 or 2015 accreditation processes.
“Installation of the magnetic door locks in September 2020 … directly addressed the specific problem that led to Mrs McKay’s death,” she said.
“I acknowledge that the door alarms installed in January 2015 went some way to mitigating the risk realised by Mrs McKay’s circumstances.
“The improvements in September 2020 came some five years after the incident involving Mrs McKay on any view, a long time.”
Goodwin has acknowledged the findings and extended its sincere condolences to Mrs McKay’s family and all those concerned.
“We acknowledge the passing of Ruth McKay in 2015, and the length of time that this process has taken, has caused significant stress and sorrow,” Goodwin said.
“In response to this incident, initial measures were implemented immediately, and further safeguards have been implemented between 2015 and now. To the best of the organisation’s knowledge, the incident in 2015 is an isolated occurrence in Goodwin’s almost 70-year history.
“The safety and wellbeing of our residents has been, and continues to be, our utmost priority.”
Coroner Taylor apologised for the long coronial process, with hearings pushed from 2019 to 2020 and the decision being handed down in April 2023.
“The delay that has attached to this process since Mrs McKay’s death in 2015 is indefensible and I will not attempt to explain it away,” she said.
“It is entirely appropriate that an apology be extended on behalf of the Coroner’s Court to the family for that delay.
“I apologise to Mrs McKay’s family for the delay and the, at times, poor communication.”
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