Summary

In May 2017, Coroner Gregory McNamara finalised his investigation into the death of an aged care resident, Mrs Moira McCarthy who died from complications related to a fall that occurred during a transfer with a lifting machine.

Background

Mrs McCarthy was a resident at Vasey RSL Care, Brighton East (Vasey Brighton East) aged care facility. At the time of her death she was 85 years of age. Mrs McCarthy was unable to speak or move independently and required 24 hour nursing care, including the assistance of two staff members for all transfers. Staff used a mobile lifting machine attached to the ceiling for all transfers.

On the morning of 24 April 2013, two personal care attendants (PCA) attended Mrs McCarthy's room to assist her to transfer from her bed to a chair. The lifting machine was attached to the ceiling tracks above Mrs McCarthy's bed and the sling was placed underneath her. The PCAs stood on either side of the bed and the lifting machine was activated with the remote control. Mrs McCarthy was then lifted off the bed.

A PCA reported hearing an unusual sound from the lifting machine, including beeping. The machine was then observed to detach from the ceiling tracks and descend rapidly towards Mrs McCarthy. Concerned the machine was going to hit Mrs McCarthy, one of the PCAs pulled Mrs McCarthy towards herself. The PCA lost her balance and fell backwards onto the floor with Mrs McCarthy hitting her head on the fall. Medical care was immediately provided and emergency services were called. Paramedics transported Mrs McCarthy to the Alfred Hospital where investigations revealed she had sustained significant head and spinal injuries. These injuries were managed conservatively and Mrs McCarthy passed away on 5 May 2013. As her death was unexpected and had resulted from an accident or injury, the death was reported to the Coroner.

WorkSafe investigation identified deficiencies

On the day of the incident, Vasey Brighton East notified WorkSafe Victoria and inspectors attended the facility and commenced an investigation. The investigation identified some deficiencies in the equipment registers including the audit sheets relating to the slings used for transfers. It was determined that these deficiencies contravened the Occupational Health and Safety Act 2004 and an improvement notice was issued.

Internal investigations into incident

Vasey Brighton East conducted an internal investigation into the incident. The PCAs were separately interviewed and an independent electrical contractor engaged to inspect the lifting machine involved in the incident. The lifting machine had last been inspected and tested on 4 April 2013.

On inspection of the machine, the electrical contractor was not able to find any fault with the functionality of the machine, or any of its safety features.

Vasey Brighton East submission to Coroner

Vasey Brighton East submitted to the Coroner that as a result of their internal investigation, the cause of the incident remained unclear. Further, there was no evidence that the incident was related to insufficient policies or practices at the facility. It was noted that all staff received training on the use of equipment and had been assessed as competent despite not receiving training in the months immediately prior to the incident.

WorkSafe investigation findings

WorkSafe provided a statement to the Coroner detailing its investigation. It was noted that the investigation established that only one of the PCAs was trained in the use of the lifting machine, that the sling had not been connected properly which allowed Mrs McCarthy to slip out and that testing of the lifting machine found no faults.

Vasey Brighton disputed WorkSafe report

In its submission to the Coroner, Vasey Brighton East disputed certain aspects of the WorkSafe report, including WorkSafe's conclusion that equipment failure was not identified as a factor in the incident. It was submitted that this conclusion disregarded the evidence of the PCAs that the machine descended rapidly towards one of the PCAs.

The Coroner's inquiries

The Coroner made inquiries regarding the PCAs qualifications and training records. The Coroner requested copies of Vasey Brighton East policies and procedures regarding manual handling and details about the training provided to staff. In April 2016, the Coroner's investigator and court staff attended Vasey Brighton East for a demonstration of the lifting hoist in action.

Coroner's finding 

The Coroner's finding detailed the improvements and changes that Vasey Brighton East had implemented as a result of both the incident and WorkSafe's improvement notice. These improvements related to compliance procedures, sling maintenance and inspections.

The Coroner concluded that:

  1. the lifting machine was in safe working order on the day of the incident.
  2. WorkSafe's report regarding the sling being incorrectly applied and connected was unable to be substantiated.
  3. in all probability, Mrs McCarthy became separated from the sling when the PCA pulled her sideways away from the descending hoist.
  4. there was no evidence available to firmly establish the cause of the incident.
  5. it was plausible that a PCA omitted to change the toggle switch on the hand held remote control from "installation" to "lifting" mode prior to activating the control buttons. This may have accounted for the unusual sounds and beeping heard by the PCAs.
  6. Vasey Brighton East acted promptly in the aftermath of the incident by providing staff with additional training in relation to manual handling and the the use of ceiling hoists, in addition to making improvements to equipment management processes.

The Coroner found that in such circumstances, it was difficult for him to find fault with the lifting machine's operating procedures.

Coroner McNamara made no criticism of Vasey Brighton East staff or its work practices.

The Coroner made a recommendation to the Victorian supplier and distributor of the lifting hoist that it notify the manufacturer regarding the need for a design review of the existing safety features within their product range in light of the circumstances of Mrs McCarthy's death.

Learnings for the health and ageing sector

The Coroner's investigation provides a useful insight into the intersection of the jurisdictions of WorkSafe and the Coroner.

Policies & procedures

Coroner's have extensive powers under the Coroners Act 2008 (Vic) to compel the production of documents and statements. This investigation emphasises the importance of maintaining appropriate, up to date policies and procedures, ensuring all staff are aware of applicable policies and procedures and arming staff with appropriate and frequent training (including refresher courses).

Accurate and up to date records

It was identified in this case that while Vasey Brighton East regularly maintained and serviced the lifting machine, the slings used for transfers were not appropriately recorded and inspected. This is a timely reminder that all health providers must maintain accurate and up to date records for all accessories used on equipment.

As Vasey Brighton East acted promptly to address the identified shortcomings around its record keeping and training, the Coroner refrained from making a specific recommendation aimed at the facility.