Mr RO’H, an aged care resident, was aged 69 when he died on 27 February 2013 from septic shock, due to or as a consequence of infected decubitus ulcers complicated by osteomyelitis.


Mr RO’H became a resident of a high care facility on 24 August 2012 when he required assistance with all daily activities and was unable to mobilise without assistance.

He experienced a number of falls during his admission and suffered from pressure sores on his heels and hips. On account of the hip sores, he was, from November 2012, to be repositioned every two hours but the progress notes did not record how frequently this happened, if at all.

On 6 February 2013, a pressure heel sore was noted to be necrotic and he was prescribed Dicolxacillin and wound dressing by the attending general practitioner. On 15 February 2013, no change to the wounds was observed despite the anti-biotics. Significant weight loss, limited oral intake, and a low blood pressure were also noted at the time.

It was not until 22 February 2013 that Mr RO’H was transferred to Hospital on the instruction of the general practitioner.

Coroner’s investigation

The Coroner’s Forensic Medical Officer investigated the death and raised concerns with the nursing care provided to Mr RO’H, the assessment of Mr RO’H’s dietary requirements, and the delay in transferring Mr RO’H to hospital once he became septic.

The Coroner obtained an expert opinion from a nurse experienced with complex wound management. The expert identified that there were lengthy delays in the facility completing Mr RO’H’s pressure injury prevention monitoring documentation, incomplete wound management forms, an overall lack of documentation that met minimum aged care standards, a lack of appreciation by staff that Mr RO’H’s malnutrition was linked to pressure ulcer formation, and a failure by staff, as of 16 February 2013, to identify severe sepsis and dehydration requiring immediate transfer.

Coroner’s recommendations

Following Mr RO’H’s death, the facility worked closely with the Office of Aged Care Quality and Compliance to rectify the identified deficiencies. This included:

• upgrading to an electronic record system that allows for the uploading of wound treatment charts;

• appointing a clinical team leader to be responsible for all management and assessment of wound care and staff education;

• the regular meeting of a wounds management team to discuss wound management strategies;

• a new pressure area audit tool to review a resident’s risk of pressure ulcers, the types of pressure relieving equipment and aids used, and whether appropriate assessments have been conducted; and

• the updating of the transfer policy to require transfer when a resident has a sudden or unexplained deterioration of condition.

The Coroner was satisfied that the changes, if followed and enforced, addressed the concerns arising from Mr RO’H’s death.


The Coroner’s investigation highlights the importance of all aged care facilities continually upgrading and reviewing their wound management/transfer policies, and ensuring that staff receive regular education in relation to each. Further, a Registered Nurse should be designated to monitor and ensure that each resident’s care is in accordance with the policies and that immediate transfer to hospital occurs if there is any concern for the resident’s wellbeing.