Inquest into the death of EW

Case Number: 2019/00217102 

Date of Findings: 4 November 2022

Magistrate: Deputy State Coroner, Magistrate Robert Stone

Catchwords: CORONIAL LAW – mandatory inquest – whether the assessment, care, and treatment of, and decision making of Regional Assessment Service and Aged Care Assessment Team staff was adequate and appropriate in the circumstances – whether a referral to dementia care and support services may be made without a formal diagnosis of dementia

Responses

Recommendations

To the First Assistant Secretary of the Australian Government Department of Health and Aged Care, Home and Residential Division:

1. That consideration be given to reviewing and updating its My Aged Care policy and procedure and other related manuals and guideline documents, with a particular focus on the “My Aged Care Assessment Manual: For Regional Assessment Services and Aged Care Assessment Teams” (and associated documents), with a view to providing for guidance in relation to:
   a. knowledge and detection of “possible” cognitive impairment and dementia
   b. assessment of mental capacity to make decisions, including decisions to consent or refuse to consent to further assessment or investigations, including further assessment by a medical practitioner; and
   c. operational expectations of RAS and ACAT assessors in relation to “Delivering Linking Support/Care Coordination to Vulnerable Clients”, particularly in relation to:
       i. clarifying the circumstances when assessors ought to provide Linking    Support to clients; and
       ii. clarifying the operation of Linking Support once implemented,    including the ongoing role of the assessor.
2. That consideration be given to reviewing and updating its My Aged Care policy and procedure and other related manuals and guideline documents, with a particular focus on the “My Aged Care Assessment Manual: For Regional Assessment Services and Aged Care Assessment Teams” (and associated documents), with a view to providing for:
   a. the collection of information during ACAT assessments that would allow for the calculation of a “possible” cognitive impairment and dementia variable; and
   b. a pathway by which ACAT assessors and delegates may (if considered appropriate) refer clients, and their carers, to appropriate dementia care and support services for clients and their carers with “possible” cognitive impairment and dementia in circumstances where the client does not have a formal diagnosis of dementia.
3. The Australian Government Department of Health and Aged Care be provided with copies of the following documents (redacted as necessary to enable distribution beyond parties):
   a. Report of Associate Professor Ryan
   b. Report of Conjoint Professor Large
   c. Transcript of 28 July 2022 expert evidence
   d. Supplementary statement of Maryanne Matthews dated 28 July 2022; and
   e. Copy of these findings.
   and to consult with the Hunter New England Local Health District on issues of concern raised by the professors and RN Matthews, including whether it is appropriate that both entities agree on whether clients without a formal diagnosis of dementia may be referred to dementia care and support services.

To the Chief Executive of Hunter New England Local Health District:

1. That consideration be given to providing RAS and ACAT assessors and delegates with training and education in the following areas:
   a. knowledge and detection of “possible” cognitive impairment and dementia
   b. assessment of mental capacity to make decisions, including decisions to consent or refuse to consent to further assessment or investigations, including further assessment by a medical practitioner; 42
   c. implications of a finding of a lack of mental capacity in NSW:
       i. need to obtain consent from substitute decision maker, who will make decisions in assessed persons best interests; and
       ii. how to identify substitute decision maker via Enduring Guardianship appointment or through application for appointment of Guardian through NCAT or the Supreme Court of NSW, or where relevant, through determination of Person Responsible under NSW Guardianship laws.
   d. operational expectations of RAS and ACAT assessors in relation to “Delivering Linking Support/Care Coordination to Vulnerable Clients”, particularly in relation to:
       i. clarifying the circumstances when assessors ought to provide Linking Support to clients; and
       ii. clarifying the operation of Linking Support once implemented, including the ongoing role of the assessor.
   The training and education contemplated by Recommendations (1) (a), (b) and (d) should reflect any update(s) in Departmental policy and procedure, and other related manuals and guideline documents as contemplated in Recommendations 1 & 2 directed to the First Assistant Secretary (see above). 
2. That consideration be given to providing education and training to ensure that RAS and ACAT assessors and delegates are aware of, and have access to advice, mentorship and supervision, in the following circumstances:
   a. evidence of “possible” cognitive impairment or dementia (such as reports of decline in cognition or behaviour from the assessed person, their carer and family, or impaired performance on cognitive testing), but there is no formal diagnosis of dementia, and where the assessed person refuses further assessment and investigation to enable diagnosis; exercise of discretion when selecting “appropriate” Supplementary Assessment Tools (SATs) as set out in the relevant guideline documents concerning same i.e. IQCODE/assessment in relation to carer/family member in conjunction with assessment of the client (under the circumstances), as opposed to reliance on “core” SATs
   b. complex and unusual circumstances, such as where a religious or cultural belief appears to be a barrier to acceptance of recommended mainstream aged support or care; and
   c. the breadth of available Linking Support / Care Coordination to vulnerable clients.
   The training and education contemplated by Recommendations 2 (a) – (c) should reflect any update(s) in Departmental policy and procedure, and other related manuals and guideline documents as contemplated in Recommendations 1 & 2 directed to the First Assistant Secretary (see above). 
3. That consideration be given to making available the education and training recommended for RAS and ACAT assessors and delegates at Recommendation 1 and 2 to health professionals who work in Community Occupational Therapy and Community Physiotherapy Services who are providing assessment, care and treatment to older clients. The training and education contemplated by Recommendation 3 should reflect any update(s) in Departmental policy and procedure, and other related manuals and guideline documents as contemplated in Recommendations 1 & 2 directed to the First Assistant Secretary (see above).
4. The LHD be provided with copies of the following documents (redacted as necessary to enable distribution beyond parties):
   a. Report of Associate Professor Ryan
   b. Report of Conjoint Professor Large
   c. Transcript of 28 July 2022 expert evidence
   d. Supplementary statement of Maryanne Matthews dated 28 July 2022; and
   e. Copy of these findings.
   and to consult with the Department on issues of concern raised by the professors and RN Matthews, including whether it is appropriate that both entities agree on whether clients without a formal diagnosis of dementia may be referred to dementia care and support services.