Inquest into the deaths of Judith Chrupalo & Christopher Clee

Case Number: 2016/77465 & 2016/77480

Date of Findings: 23 December 2021

Magistrate: Deputy State Coroner, Magistrate Derek Lee

Catchwords: CORONIAL LAW – cause and manner of death, identity of deceased persons, NSW Public Guardian, Dubbo Base Hospital, Lourdes Hospital and Community Health Care Service, NSW Civil and Administrative Tribunal, guardianship application, Aged Care Assessment Team, assessment of capacity self-discharge against medical advice, service providers, elder abuse, self-neglect, community nursing care, welfare checks.

Responses

Recommendations

To the Secretary of NSW Health:

1. I recommend that NSW Health review The Guardianship Application Process for Adult Inpatients in NSW Health Facilities (GL2017_013) in relation to the requirements for making an application under the Guardianship Act 1987, particularly in relation to the concept of disability, including physical disability, and the Health Guardianship Project. 

To the Chief Executive, Western New South Wales Local Health District:

1.  I recommend that Dubbo Base Hospital introduce procedures and provide training to staff in relation to guardianship applications that set out:
   (a) the circumstances in which it is necessary and appropriate to make an application;
   (b) who is responsible for coordinating such an application;
   (c) the requirements for guardianship applications, including the reports to be provided to the NSW Civil and Administrative Tribunal and appointed guardian to support the application and guardianship process (whether a private guardian or the Public Guardian is appointed); and
   (d) coordination with the Office of the Public Guardian in relation to the Health Guardianship Project.
2. I recommend that Dubbo Base Hospital introduce procedures and provide training to staff for capacity assessments that:
   (a) set out the appropriate circumstances where such assessments should be undertaken;
   (b) identify who the appropriate health practitioners and/or clinicians may be depending on the nature of the assessment;
   (c) identify the appropriate range of assessment tools are available;
   (d) require early referral for capacity assessments, pre-discharge, to ensure adequate time for undertaking an assessment;
   (e) identify the available options for a capacity assessment or other negotiator pathways that are available where there is a possibility of discharge without medical advice;
   (f) ensure that, if there is a referral to a clinician for assessment, the purpose(s) of such assessments are clearly identified and documented and all relevant information is made available to the clinician conducting the assessment;
   (g) ensure that ultimately the assessment is undertaken within a multidisciplinary framework; and
   (h) require documentation of any assessment, including any tests undertaken.
3. I recommend that Dubbo Base Hospital review procedures for discharge against medical advice and advance discharge planning to ensure that the health and welfare of patients is protected with adequate post-discharge support that is consistent with the Hospital’s duty of care. 
4. I recommend that Dubbo Base Hospital introduce written procedures and provide training in relation to elder abuse, neglect and exploitation of patients, which provides guidance on the indicators, the means of responding, and the duty of care and responsibilities of staff. Such procedures and training would refer to the procedures relating to appointment of the Public Guardian or a hospital guardian, the availability of assistance from the Ageing and Disability Commission and the operation of the Health Guardianship Project.

To the Chief Executive, Lourdes Hospital and Community Health Services: 

1.  I recommend that Lourdes Hospital and Community Health Services (Lourdes) review procedures for discharge, including against medical advice, to ensure that the health and welfare of patients is protected and consistent with Lourdes’ duty of care, including ensuring that Lourdes has:
   (a) received a direct communication from the patient that he or she no longer wishes to receive care (a communication from a carer being insufficient) before discharge;
   (b) liaised directly with the patient’s general practitioner regarding the possibility of discharge; and
   (c) has before discharge, informed the patient of the possibility of discharge and what other services are, or are not, available.
2. I recommend that Lourdes Hospital and Community Health Services introduce written procedures and provide training to staff in relation to guardianship applications that set out:
   (a) the circumstances in which it is appropriate to make an application;
   (b) the requirements for guardianship applications;
   (c) the information and support to be provided to the NSW Civil and Administrative Tribunal and appointed guardian to support the application and guardianship process (whether a private guardian or the Public Guardian is appointed);
   (d) the role of the Public Guardian once appointed; and
   (e) co-ordination with the Office of the Public Guardian in relation to the Health Guardianship Project. 
3. I recommend that Lourdes Hospital and Community Health Services introduce written procedures and provide training in relation to elder abuse, neglect and exploitation of patients, which provides guidance on the indicators, the means of responding and the duty of care and responsibilities of staff. Such procedures and training would refer to the procedures relating to appointment of the Public Guardian or a hospital guardian, the availability of assistance from the Ageing and Disability Commission and the availability of the police to assist in providing welfare checks.

To the Chief Executive Officer, New South Wales Trustee & Guardian:

1. I recommend that New South Wales Trustee & Guardian provide training to staff within the Office of the NSW Public Guardian in relation the Policy: Recognising and responding to allegations of violence, abuse, neglect and exploitation of customers.