Betty Christine Quayle died on 31 May 2013 at the age of 89 years. She was admitted to hospital after being assaulted by a fellow resident who suffered cognitive impairment at her aged care facility.

The cause of death was a blunt force head injury as a result of the fellow resident using a pillow and / or other means during the assault.

Background Facts

Mrs Quayle was a resident at an aged care facility after experiencing functional decline and fragility.

At about 3.00am on 30 May 2013, Resident A, another resident at the aged care facility who suffered from cognitive impairment, wandered from his wing and inadvertently into Mrs Quayle’s room. Believing he was in his room, Resident A told Ms Quayle to wake up and get out of his bed. Mrs Quayle was unable to respond to him. Resident A then attempted to remove her from the bed, assaulting her a number of times and causing a number of injuries.

Mrs Quayle was transported to hospital and died the following day at 2.30pm.

After conducting an autopsy, the forensic pathologist opined Mrs Quayle’s cause of death was a blunt force head injury. Although the extent of Mrs Quayle’s brain injury was less than would usually be expected to cause death, the forensic pathologist was of the opinion that it was likely that Mrs Quayle’s death was the consequence of a background of severe heart and lung compromise, with superimposed consequences of blunt force tissue injury and subdural bleeding.

Patient A was known to be aggressive and wandered frequently. He was therefore placed in a locked, secure unit within the aged care facility on his admission in May 2011. In October 2011, Resident A was moved to a non-secure unit at the suggestion of his general practitioner in an attempt to decrease his frustration and aggression. While living at the aged care facility, Resident A was violent towards staff and other residents, regularly absconded from the facility, consumed alcohol at local hotels, refused to take his sleeping and mood stabiliser medication, and entered other patients’ rooms.

In response to Mrs Quayle’s death, the aged care facility:

  • Counselled nursing staff on the relevant policies and procedures, including how to respond to an emergency;
  • Provided refresher training to staff on missing resident procedures; and
  • Introduced a Riskman system to capture trends and near misses, such as aggressive behaviour.


Resident A was initially charged by the police with grievous bodily harm, and this was subsequently upgraded to manslaughter. On 16 June 2016, the Mental Health Court found that Resident A was of unsound mind at the time of Mrs Quayle’s death and the manslaughter charge was discontinued.

The Australian Aged Care Agency (AACA) conducted an audit 5 weeks after Mrs Quayle’s death and concluded the aged care facility met the expected outcomes for ‘behavioural management’ and ‘physical environment and safety’.


The Coroner made the following findings:

  • Mrs Quayle died of a blunt force head injury as a result of Resident A using a pillow and / or other means during the assault;
  • The fragility of Mrs Quayle’s body tissue, as evidenced by the autopsy, demonstrated her vulnerability and her requirement for care and protection;
  • The aged care facility failed to adequately manage the risk of harm posed by resident A, as demonstrated by his continued violence and aggressive behaviours, including after he was moved to the non-secure environment in an attempt to decrease his frustrations;
  • Had the aged care facility adequately managed this risk, Mrs Quayle’s death could have been prevented;
  • The AACA’s response and report was inadequate as it failed to identify whether specific or general regard was had to Resident A’s behaviours in the months leading to Mrs Quayle’s death and failed to identify what other examinations were conducted by the AACA after Resident A was first admitted to the facility.

The Coroner referred the matter to the Aged Care Quality and Safety Commission, the Secretary of the Department of Health and the Royal Commission into Aged Care Quality and Safety.