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WA Coroner makes recommendations regarding home care

09 Mar 2017

The Coroner’s report concerned the death of Mrs Maria Carmel Niceforo (the deceased). Mrs Niceforo was a 75-year-old woman who suffered from a number of age-related illnesses including type II diabetes and ischaemic heart disease. She was born in Italy and emigrated to Australia. At the time of her death, she resided at home where she received some support from her adult children. She also received care and services from a home care provider under an Extended Aged Care at Home (EACH) Package.

At the time of her death, the deceased was receiving personal care (hygiene) and wound care from an approved provider of home care. The wound care was to treat a number of pressure wounds which the deceased had developed on her legs and sacrum.

The Coroner found that the cause of the deceased’s death was organ failure due to sepsis, likely from infected pressure sores, in the context of uncontrolled diabetes mellitus and ischaemic heart disease.

Comments on the care provided by the home care provider

The Coroner made a number of comments on the home care provider’s actions and the quality of care and services provided to the deceased:

  • Treatment provided by staff

In the Coroner’s view, the treatment and care provided by staff was generally at a reasonable standard. The standard of wound care was also reasonable in the circumstances, having regard to the evidence that the deceased often consciously refused to adopt advice in relation to relieving pressure on the wounds.

However, the provider had inefficient communication systems in place. That inefficiency, together with a language barrier arising from the deceased’s difficulty speaking English, led to a potential for nurses to misapprehend the details of the care they were supposed to provide.

While there were areas where the provider could have improved, the provider’s failures did not contribute to her death.  

  • Role of the family in her care

Staff thought the deceased was showered by her family on weekends, which was not the case. Staff also thought directions were given to the family to assist the deceased with mobilisation to relieve some pressure over the injured tissue, however the deceased’s daughter said she did not remember the nurses encouraging the deceased to mobilise and for the daughter to assist her (although she did assist the deceased to walk around and go outside).

  • Failure to provide supplies

The provider failed to provide their nurses with all the supplies they required in order to treat the deceased. However the Coroner found there was no evidence to establish that this failure had any substantial negative effect on the deceased’s physical health as the family bought the necessary supplies so the deceased did not miss out on dressings

  • Failure to provide staff on weekends and holidays

The care and treatment provided by the provider was limited by funding available in the package. The deceased received the highest care available relative to that funding and it was not reasonable to expect provider to provide higher care without compensation.

The Coroner concluded that the provider’s care and treatment of the deceased was hampered by its regular on-going failure to supply dressing supplies for nursing staff, by inefficient and confusing means of communication between staff members, and by an occasional lack of support, including lack of supervision and training. However, there is no evidence to establish that those inadequacies resulted in a level of care that was so substandard as to contribute to the deceased’s death.


The Coroner made two recommendations, both of which are of specific relevance to home care providers:

  • Recommendation 1: That, if reasonably practicable, organisations providing home care generate a document describing the roles and responsibilities of each person involved in a patient’s care, including where applicable the patient’s family or friends, and provide a copy of such a document to those persons at the outset of that care and from time to time as is reasonably necessary.
  • Recommendation 2: That, home care providers assess their patients’ needs on an on-going basis and, where a home care provider considers that the care it is able to provide to a patient under a home care package cannot meet the patient’s needs, the home care provider meet with the patient and the patients’ next of kin where appropriate to so inform the patient and to discuss the patient’s further care.

Key lessons

In the Coroner’s view, the two most important lessons to be learned from the deceased’s sad death are:

  1. care plans for care recipients in a home care situation need to be reviewed regularly and whenever a change in the care recipient’s condition occurs; and
  2. in circumstances where a care recipient is partly reliant on the care of family members or other persons who are not health care providers, those persons need to be involved so far as is practicable in the care planning, including on-going reviews of that planning. In that way, they will have reasonable expectations of the type and level of care provided by the health care provider, they will be aware of their roles and responsibilities, and the health care provider will be aware of the level of care provided by those persons.

Hynes Legal provides expert legal advice in home care. Please contact us if you have any questions about the Coroner’s decision or would like any advice about how the decision affects your organisation.


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