Hobart wound care fatality a reminder to aged care executives of need for robust and resilient systems of care

More than three years after an 87-year-old woman passed away, a coroner has ruled that both systemic and human error contributed to her death. A Tasmanian aged care home failed to adequately treat a pressure wound that had become infected. In February 2022, the woman died at Hobart’s Fairway Rise facility after her sacral wound had gone un-checked for weeks, resulting in a severely infected stage-four sore.

After an investigation into the lead up and eventual fatality, Coroner Mackey stated that the facility’s systemic electronic alert system was made redundant due to the lack of input by staff. A new wound chart was never entered into the system, nullifying the process of automatic reminders to perform wound care.

The incident in Hobart highlights the critical need for provider leadership and clinical risk management staff to develop systems that are dynamic in their process and alerts. While electronic systems are heavily relied upon by the large majority of providers, limiting checks to a response to electronic alerts narrows pro-active and preventative care. It also raises the implication that digital reminders may not be a full-proof method to rely upon to prevent wound deterioration. Risk management must be a multi-pronged approach through electronic, analogue and human processes and reminders.

Mackey notes in her report that, “The facility failed to comply with the wound management plan it had developed.” Continuing, “It did not recognise [her] deteriorating condition or adapt to her evolving care needs.”

The findings are a stark reminder to care and risk management for providers across the board, even with in-house bespoke systems, with one track points of oversight, and reliance on a singular electronic alert system to check wounds, timely and critical care can become compromised.

The report further details that the wound was left to progress between the dates of January 19-26, a full eight days, and then again from January 29 – February 6, a further nine days. Coroner Mackey found that it was detailed that the woman was showing signs of weight loss and confusion, which in her opinion, should have alerted staff to act.

Coroner Mackey’s report further delves into contextual factors that contributed to lack of oversight of care. While increasing the difficulty of communication, oversight and compliance, Mackey’s findings further entrench the essential need for executive provider oversight in planning excellence of care through the difficulty of staff absences, turnaround and vacancies. Care must be highly managed within this and any environment.

The report notes that staffing challenges were occurring during this time with the clinical care coordinator returning from an absence and a facility manager position unfilled.

Medically, the forensic pathologist assigned to the investigation found that the woman died from “chronic obstructive pulmonary disease”, formally noting that a contributing factor was the infected wound.

The Coroner handed down four recommendations following her investigation into the incident, starting with ensuring that all nursing staff at the facility undergo regular wound care competency checks.

She also recommended and highly stressed the need for dynamic care planning at regular stages, more robust workflow systems and systemic weekly management reviews of wound charts.

The incident is a reminder of the complexities of providing excellence in care within difficult and highly-changeable labour and procedural environments. There is significant onus on the preparation of resilient, multi-faceted and comprehensive risk and care management. The regular assessment, creation and re-evaluation of these processes by leadership at all levels of aged care executives is a necessity to prevent the preventable incident of February 2022.

Entering into a voluntary agreement with the Aged Care Quality and Safety Commission in December 2023, the facility has conducted specific education programs on wound care, addressed policies and pivoted to alternative wound care products.

Mackey has noted, “the steps they have undertaken to prevent omissions in care such as occurred here from occurring again.”