"My mother's fatal accident at Algester Lodge"

About: Algester Lodge Nursing Home

(as a relative),

Our mother was admitted to a high care room at Algester Lodge (QLD) after being diagnosed with dementia, and having been assessed to be unable to return to her home by QLD Health during a stay in PA Hospital after a fall at home.

In December 2013 mum fell late at night at Algester Lodge in the dining room unwitnessed by staff.

Algester Lodge stated originally to us that mum fell around 10.00pm and was found by staff 15 to 20 minutes later. Algester Lodge later told us the incident was "recorded at 10.45pm".

We have subsequently reviewed Queensland Ambulance records which show Algester Lodge phoned Queensland Ambulance at 11.02pm.

Queensland Ambulance records show that upon arrival Queensland Ambulance officers assessed mum to be suffering "Closed Fractures" and "Suspected Spinal Cord Injury" - with Ambulance officers also noting that upon their arrival Algester Lodge staff had already tried to lift mum from the floor using a hoist causing mum to be "crying out in pain". Queensland Ambulance assessment of mum at the injury site noted an obvious likelihood of a serious pelvic/right leg fracture based on "shortening, swelling, deformity and loss of function".

In subsequent discussions with Algester Lodge we were told that mum had been wandering at night for some time - yet we had never been told this was happening.

The first notification we received regarding mum's fall was a phone call at 3.45am from the Emergency department at QEII Hospital - the hospital staff that contacted us seemed surprised our family had not yet been advised of mum’s fall and initially asked us if we realised our mother had been in Emergency for over 4 hours?

At about 7.00am the next day we received our first contact from Algester Lodge saying that there had been "an incident" the night before and that mum had fallen and hit her head, had some skin tears and had been taken to hospital by ambulance.

At this point we noted to Algester Lodge that mum was at QEII in a critical condition where doctors had assessed her to have severe skull and pelvic fractures and bleeding on the brain – indications were that she would likely not live through the next 24hrs.

In a subsequent telephone discussion with Algester Lodge we asked why we had not been informed by them immediately at 11.00pm that mum had suffered a major injury and been sent to hospital by ambulance, and why it has taken Algester Lodge until 7.00am the next day to contact us for the first time. Algester Lodge stated that this was due to their Registered Nurse on-duty at the time of mum’s accident not having been present at a previous meeting Algester Lodge had held with mum’s ward staff and presumably not having been aware of the need to contact us.

(Our family had only in recent weeks met with Algester Lodge specifically to remedy similar multiple failures of communication where our family had not been notified of issues and occurrences with mum at Algester Lodge – our understanding of the outcome being that Algester Lodge assured us this situation had been corrected).

When we suggested to Algester Lodge that any Registered Nurse surely would - beyond any other procedural requirement - immediately inform us of such a serious accident requiring ambulance and hospital - Algester Lodge stated that we needed to understand that often when their staff phoned families at late hours they suffered abuse from relatives who didn't like being disturbed.

Algester Lodge seemed unable to explain how mum had wandered late at night so far from her own room to the dining room - taking her directly past the nurse’s station - without being seen by any staff. Algester Lodge inferred that the nurse’s station would have been staffed, but we had noted on numerous visits that this was not always the case.

The delay of several hours in notifying us of mum’s accident prevented any of our family from attending and comforting her ASAP. Queensland Ambulance records show that upon her transport to, and admission to Emergency at QEII Hospital mum was conscious and communicative - this being noted by hospital doctors as well. However by the time we were informed and arrived at the hospital she was unconscious, which deprived us of our last chance to speak with her in any meaningful way, or knowingly comfort her.

Mum died in hospital 7 days later as, we believe, a result of the fatal injuries she suffered in this fall at Algester Lodge.

In particular the issues for us with Algester Lodge we note in this case are:

* Failure to notify us of mum having taken to wandering at night for some time, and what appears to be a failure to enact any control on this unsafe behaviour.

* Failure to have what we believe to be adequate supervision in place to note a patient with dementia wandering far from her own room late at night - especially given her route took her directly past a nurse’s station.

* Failure to immediately and as we believe should be a matter of course to call Queensland Ambulance given Algester Lodge state mum was found somewhere between 10.00 and10.45pm, yet Queensland Ambulance was only phoned by Algester Lodge at 11.02pm.

* Failure to enact seemingly safe medical care upon finding mum – who, we believe, was clearly suffering a very serious state of multiple injury - by attempting as a seemingly first choice to lift her from the floor of the dining room using a hoist before Ambulance officers had even arrived. The state of her serious injuries was obvious to Queensland Ambulance upon their arrival.

* An apparent gross failure to notify family of mum’s clearly extremely serious injury until at least 8 hours later, and thereby many hours after we'd been alerted by QEII Hospital who assumed we'd already been told by Algester Lodge.

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Responses

Response from Patient Opinion Australia

This response has been posted by Patient Opinion on behalf of Algester Lodge

The passing of any resident is heartbreaking for the families and for our staff. We would like to express our sincere condolences to our resident's family and loved ones.

Our residents become part of our extended family. As would be the case with any passing we have continued to talk with the resident's family as they go through the grieving process. This resident has lived at our nursing home since 2010. We have had regular contact with two of her children during this time and since their mother passed away. We have not had any contact from her other children while she has been a resident. We understand this particular complaint to Patient Opinion was made by a family member that we have not had any previous contact with.

In this particular case when our resident was sent to hospital, we called the resident's daughter as we held her details as the resident's contact. It is very unfortunate that the nurse who called the family did not do so for several hours after the resident had been transferred to hospital. This was contrary to our protocol and occurred purely because of human error. The staff member in question has been disciplined and we have apologised most sincerely for the delay to the family members we know.

As a result of the complaint, we have appointed an independent party to investigate this case further to see if anything should have been managed differently.

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Update posted by concernedson (a relative)

It is astonishing - given the severity of this case - that Algester Lodge seems to have failed to respond on any of the specific and critical points we raise in our story.

I feel that in this case "sorry" is a deficient response - when clearly admission, explanation and remediation for the future about what happened should be a minimum reaction.

The posted comment by Algester Lodge about having "called the resident's daughter as we held her details as the resident's contact" seems to suggest excusal of their gross failures - not any explanation as to why such a call about such a fatally serious accident took at least 8 hours to make.

This comment also ignores the fact that Algester Lodge at all times held contact details for - and had previously phoned - a second child who, I believe, had only in weeks recent to this accident met with them to insist on their correction of their multiple previous failures to contact or notify anyone of happenings with mum.

Further - ever since our mums admission to Algester Lodge and in particular since this meeting with Algester Lodge in the weeks most recent to this accident occuring - all contact details for all of mums children have always been supplied to, and noted by Algester Lodge.

Contrary to this response from Algester Lodge - the only contact, I am aware of, made between them and our family following their initial phonecall at least 8 hours after mum had fallen and been ambulanced to hospital was a phone conversation - at our instigation (as mentioned in our story) - and a sympathy card received by mail some weeks after mums funeral.

The posted comment by Algester Lodge that they "have not had any contact from her other children while she has been a resident" seems to imply a lack of care by these "absent" relatives - which I believe is disgusting. This, I feel, is particularly offensive and untrue given that these children actually live interstate in remote regional locations, yet still have, between them, visited Algester Lodge scores of times to visit mum since she was admitted.

Finally, we request Algester Lodge to detail here on Patient Opinion what "independent party" has been appointed to investigate this case - and why, it seems, our family has not been notified of this given Algester Lodge have immediately announced this having been instigated in their post to Patient Opinion?

Response from Patient Opinion Australia

This response has been posted by Patient Opinion on behalf of 'Another Son'.

I am another concerned son, one of the two of Mum's children who had regular contact both with Mum and staff during her time at Algester Lodge.

My brother makes some valid points which I believe are satisfactorily addressed in the response posted by Algester Lodge. Human error has been admitted and independent investigation is to be commissioned. I believe this demonstrates a willingness to remedy any shortcomings in the present system.

My brother's submission seems to imply almost deliberate negligence on the part of Algester Lodge. I don't believe this is the case and hold no-one responsible for Mum's tragic accident. Hopefully we can now all move on, shifting our attention from accusations.

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