Eight frail Victorians died in aged care “resident on resident” aggression in just nine months, prompting an investigation to determine what more can be done to protect those suffering from dementia and mental health issues.
The tragedies occurred in six aged care facilities in Melbourne and regional Victoria in 2021 and all involved residents suffering fatal injuries after being pushed or struck by counterparts with cognitive impairments.
The eight residents died in six different homes in 2021.Credit: iStock
A coroner has grouped the deaths together as an “aged care aggression cluster” to probe whether gaps in federal and state oversight of the aged care sector, as well as any failings at individual facilities, can be identified and overcome to prevent further fatalities.
On the first day of a five-day inquest, Deputy State Coroner Paresa Spanos heard on Monday that research had shown resident-on-resident incidents were not random or unpredictable events, but could be anticipated and avoided by examining individual risk factors, triggers and environmental settings.
Naomi Hodgson, counsel assisting the coroner, said research indicated that nine out of 10 people involved in such incidents had some form of cognitive impairment, and those involved in the Victorian cluster were not aware of their actions and should not be viewed as perpetrators.
“While it sometimes may involve a level of frustration or anger on the part of the person who pushes or strikes another person, it may be that they are simply, impulsively, pushing out past a person to achieve their immediate goal,” Hodgson said.
“It’s important to note that the so-called aggressors in resident-on-resident aggression … would not be reviewed as having an intention to harm people or having an understanding of the ramifications of their actions.”
Between March 28 and December 20, 2021, Angela Linkiewicz, Caterina Kamber, Michael Karonias, Alfred Roy, Norat Manouelian, Beverly Bartlett, Kevin Withers and George Ward all lost their lives in incidents of resident-on-resident aggression.
The deaths occurred at Eastern Health’s Peter James Centre in Forest Hill, Shepparton Villages, the Noel Miller Centre in Glen Iris, Narracan Gardens in Newborough, Alexander Aged Care Centre in Clayton, and Samarinda Lodge in Ashburton.
Hodgson said five of the residents died after suffering hip or pelvic fractures as a result of being pushed or struck, while the others suffered subdural haematoma as a result of head injuries.
“What may otherwise be a benign or innocuous action in another setting becomes serious and, in these cases fatal, because of the vulnerability of the residents in residential aged care,” she said.
Eastern Health’s Peter James Centre.Credit: Easternhealth.org.au
“In each case it appears that if it happened to a younger person without comorbidities the incident may not have resulted in death or even injury.”
At the time of the deaths there were 240,000 Australians in aged care, including 54 per cent with diagnosed dementia.
The coroner heard that while the federal government was opening services through its Dementia Care Program, fewer than 300 of the specialist beds would be available nationally when the program was fully implemented.
The Victorian government also oversees an unspecified number of aged care in-patient psychiatric beds as well as residential aged care mental health services attached to each of the state’s 17 health networks, the Coroner’s Court heard.
Hodgson said the Commonwealth’s National Dementia Training and Education Standards Framework provided thorough guidance for aged care staff following the 2021 Royal Commission into Aged Care Quality and Safety, but the coroner’s investigation needed to explore whether aged care homes are aware of, or implementing, the directives.
During questioning on the death of Linkiewicz, Eastern Health director of nursing residential aged care Wendy Calder said a lot had changed at the Peter James Centre in the four years since the tragedy.
Linkiewicz was diagnosed with late onset schizophrenia in 2020 and admitted to the Northside Aged Psychiatric Residential Care facility at the centre, where she had shown significant ongoing behavioural disturbance towards staff and other residents, due to her impairment.
On March 25, 2021 Linkiewicz was upset and used a walker to move towards her counterpart. She continued to scream at them and, although a nurse tried to reassure the counterpart, they became distressed and pushed Linkiewicz’s shoulder and she fell. She was taken to Box Hill Hospital by ambulance and diagnosed with a hip fracture but, three days later, became unresponsive and could not be resuscitated.
“The interaction was really unfortunate. It was supervised and it couldn’t be prevented. It doesn’t seem to be a lot of interaction between the two of them,” Calder said.
As well as a redesign of the unit so residents no longer share rooms, Calder said there are additional staff on each shift, and weekly reviews of individual resident care plans are undertaken when residents’ behaviours change.
“I think it is more robust now. It has grown over the four years,” she said.
The hearing continues.
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