In April of this year, the New South Wales Coroner’s Court handed down a finding1 in relation to the death of an aged care resident, Mrs Patricia Northcote, as a result of sepsis arising from a urinary tract infection and a sacral area pressure sore.

Background and finding

Mrs Northcote, a paraplegic, required assistance to transfer from her bed to her wheelchair. Her preference was to use a slide board and she continually resisted staff attempts to use a hoist or lifter instead. Staff were concerned that slide board transfer was unsafe.

In an attempt to resolve the standoff, second opinions were sought from a physiotherapist and rehabilitative medicine specialist. Both considered that Mrs Northcote was capable of moving herself by slide board, with assistance from staff to move her legs. The practice therefore continued, despite a work health and safety assessment that the method was unsafe both for Mrs Northcote and for staff.

On 1 November 2012, a nurse observed a small area of broken skin over Mrs Northcote’s sacral area, and consideration was given as to whether the side board had caused it. Whilst she initially complied with staff direction regarding care of the sore, from 7 November, she began to refuse to have dressings applied. Subsequently, the sore increased in size and redness.

On 16 November 2012, it was noted that the sore had deteriorated significantly and was now described as an increased size ulcer on the sacrum and coccyx, with very red, purple and slightly black skin. On account of this observation, care of the wound was escalated. A photograph was taken, a telephone message left with Mrs Northcote’s general practitioner and a pressure area chart commenced with a direction from facility management for two hourly observations and repositioning. This direction was not complied with on a consistent basis and the pressure area chart was abandoned after two days. On 22 November 2012, Mrs Northcote was transferred to hospital due to being delirious and febrile. The hospital observed a significant pressure sore that, once debrided, was 5cm in depth. Mrs Northcote died in hospital on 7 December 2012.

The Coroner held that Mrs Northcote should have been transferred to hospital sooner, but doubted, based on the expert evidence before the court, whether an earlier transfer would have made any difference to the outcome. The Coroner also found that Mrs Northcote’s continual non-compliance with staff direction throughout the relevant period, contributed to her deteriorating condition.

In addition, one of the expert witnesses opined that the pressure care and wound management was “less than adequate”. Staff relying on Mrs Northcote to “rock herself on her buttocks in her chair in order to relieve pressure” was an inadequate method of pressure area care management. The expert said that a facility needs to be very strict about repositioning residents in order to effectively treat a pressure sore, and questions were raised about why the facility did not commence a repositioning chart for more than two weeks after the sore had first been identified.

The Coroner held that the facility failed to adhere to its own policy regarding pressure sores, including the need to complete a resident incident form, take a photo and complete a treatment plan upon initial identification. However, while the facility’s failures around observation and re-positioning may have contributed the the deterioration of Mrs Northcote’s sacral area, overall these failures were of limited practical consequence as staff ultimately became aware of the injury soon after it was first identified and treatment was commenced.

A further contributing factor was the evidence that Mrs Northcote had not been properly assessed for dementia. Some facility staff considered that Mrs Northcote’s condition was normal for her age, however the expert considered that Mrs Northcote suffered from vascular dementia of moderate severity.

If the dementia had been properly considered and diagnosed, it was the expert’s opinion that Mrs Northcote would have been case-managed by an appropriate professional, such as a geriatrician, allowing for a holistic management approach and the implementation of system of case conferences between practitioners, staff and family to ensure consistency in care.


The facility was commended for having implemented a number of changes following Mrs Northcote’s death, including increasing staffing levels, policy improvements, further training on wound management and behaviour, and participating in a pilot standards program. Further, the facility had now begun utilising case conferences to ensure consistency of care between practitioners, staff and family.


In addition to educating staff about the importance of adhering to patient management plans, it is imperative that all aged care organisations implement adequate policies and procedures in relation to wound management, including regular repositioning, wound care, dressing, involvement of relevant medical practitioners, communication with family, and frequent reassessment of care plans, including resident transfer methods. The Coroner’s finding demonstrates what can happen when facility staff fail to provide consistent care, adhere to policies, or fail to regularly involve medical practitioners and not have a resident’s cognitive impairment reviewed in light of an increased refusal to adhere to staff directions.