Inquest into the Death of Kathryn PAPANASTASIOU

Inquest into the Death of Kathryn PAPANASTASIOU

Delivered on : 11 October 2023

Delivered at : Perth

Finding of : Coroner Jenkin

Recommendations : Yes

Recommendation No. 1

I recommend that Brightwater Care Group amend its policy documentation to make it clear that when a resident is being transported in a wheelchair, a three point restraint system (consisting of a pelvic lap sash and a shoulder strap) is to be used to secure the resident in their wheelchair.

Recommendation No. 2

In order to ensure that the straps used to secure residents being transported in wheelchairs are serviceable and available to all users, I recommend Brightwater Care Group consider:

  1. Clearly labelling each set of straps;
  2. Conduct regular audits of the straps in each of its vehicles to ensure the straps are present and serviceable; and
  3. Amend its policy documentation to make it clear that those staff responsible for refurbishing a vehicle used to transport residents are to ensure that after a trip has concluded, all straps used to secure residents in their wheelchairs are stowed away neatly in pairs, so that the straps are available for the next user of the vehicle.

Recommendation No. 3

I recommend Brightwater Care Group amend its policy documentation to mandate annual mandatory refresher training for all staff responsible for driving vehicles used to transport residents.

Orders/Rules : No

Suppression Order : N/A

Summary : Ms Kathryn Papanastasiou (Ms Papanastasiou) was 74-years of age when she died at Sir Charles Gairdner Hospital (SCGH ) on 15 March 2020 from fractures of the legs.

At the relevant time, Ms Papanastasiou was a resident at Brightwater Onslow Gardens (Onslow), an aged care facility in Subiaco run by the Brightwater Care Group (Brightwater).  As a result of her medical issues, Ms Papanastasiou was confined to a wheelchair and on 4 March 2020, she and several other Onslow residents were being taken to an event at Optus Stadium by bus.

Ms Papanastasiou was loaded onto the bus in her wheelchair, but the bus driver was unable to locate a lap-sash strap set, and Ms Papanastasiou was secured in her wheelchair using a shoulder strap.  On the way to the event, the bus driver braked suddenly, causing Ms Papanastasiou to fall out of her wheelchair and onto the bus floor where she sustained serious injuries.

Ms Papanastasiou was taken to SCGH by ambulance where scans confirmed she had fractured bones in both of her legs.  After discussions between her family and her treating team, it was decided Ms Papanastasiou was not a suitable candidate for surgery.  Instead she was treated palliatively, and kept comfortable until she died.

The Coroner concluded that at the time of the accident, Ms Papanastasiou had not been restrained in her wheelchair in accordance with Brightwater’s policies.  The coroner noted that since Ms Papanastasiou’s death, Brightwater had made comprehensive changes to their driver training regime and their policies relating to the transport of residents in its vehicles.  The coroner made three recommendations aimed at further strengthening resident safety.

Catch Words : Transport of wheelchair occupant : Aged care resident : Chronic Medical Conditions : Natural Causes


Last updated: 20-Oct-2023

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