Staff cuts faulted in nursing home death


A NOBLE PARK nursing home had been trialling staff cuts at the time a resident died on Black Saturday, the coroner has found.

Joan Ambrose, a patient suffering with dementia, was found lying in a courtyard

outside the Noble Manor Nursing Home on the afternoon of February 7, 2009.

It is believed the 79yearold left the nursing home shortly after 1pm and her body was

discovered by staff three hours later in temperatures “almost certainly greater” than the 46.4 degrees recorded in Melbourne that day.

Mrs Ambrose had left through a door that allowed for the easy exit of residents but required anyone re-entering to gain the attention of someone within.

Conducting an inquest into Mrs Ambrose’s death, coroner Peter White said it was “self evident” that elderly residents were especially at risk on days like Black Saturday and “such risk may be offset by the level of care provided by any particular facility”.

Mr White said Noble Manor management trialled staff reductions on the afternoon of Mrs Ambrose’s death and only two personal-care assistants were on duty between 1pm and 3pm.

“Management failed to make appropriate plans to protect Mrs Ambrose on February 7 and this failure contributed to her death,” Mr White said.

The plan to reduce staffing that afternoon should have been postponed and the staffing trial had “further compromised management’s ability to ascertain that Mrs Ambrose was missing”.

TLC Aged Care chief executive Ingrid Williams said Noble Manor supported the coroner’s findings but disputed that staff changes contributed to Mrs Ambrose’s death.

“The staff numbers at the time were appropriate for the number of residents in the facility,” Mrs Williams said.

The nursing home had learned from the tragic event by investing in new doors and updating policies for days of extreme heat.