A Tasmanian aged care home’s failure to treat an infected pressure wound has been found to have contributed to the death of an 87-year-old woman.
The woman died in February 2022 after staff at Hobart’s Fairway Rise facility failed to check her sacral wound for weeks, allowing it to progress to a severe and infected stage-four sore.
Coroner Leigh Mackey found the facility’s electronic alert system broke down because staff never created a new wound chart — meaning no automatic reminders were sent when care was missed.
“The facility failed to comply with the wound management plan it had developed,” Mackey said. “It did not recognise [her] deteriorating condition or adapt to her evolving care needs.”
The wound went unchecked between January 19–26, 2022 and again from January 29 to February 6.
During that time, the coroner said the woman showed signs of confusion and weight loss that should have prompted action.
Staffing changes, including the clinical care coordinator returning from maternity leave and a vacant facility manager position, further reduced oversight, the investigation found.
A forensic pathologist determined the woman died from chronic obstructive pulmonary disease, with the infected wound a contributing factor.
Mackey has made four recommendations as a result, starting with regular wound care competency checks for all nursing staff.
She also urged dynamic care planning using standardised tools such as the Waterlow pressure ulcer scale, with assessments on admission, at regular intervals and whenever conditions change.
Other recommendations included stronger workflow systems with clear care instructions, automatic alerts when tasks are missed and weekly management reviews of all wound charts.
Since the woman’s death, the facility has rolled out targeted education programs, updated policies and brought in new wound care products.
It entered a voluntary agreement with the Aged Care Quality and Safety Commission in December 2023.
“I acknowledge the steps they have undertaken to prevent omissions in care such as occurred here from occurring again,” Mackey said.
