The NSW State Coroner delivered findings into the Inquest of the death of Melissa Standen on 25 September 2018. Madeleine Bridgett represented Mr Bruce Standen, Melissa’s father. The Coroner found that the manner of death was a fall from a bed at Allowah Hospital due to failures to implement proper systems for risk assessment, bed selection and the training of staff for a child patient with profound disabilities.
The Coroner found that the following factors contributed to Melissa falling from the bed and her subsequent death: failure by the hospital to develop and implement an appropriate risk assessment and admission procedure; failure to implement a proper risk assessment to manage Melissa’s change from a cot to a bed; the selection and use of a bed totally unsuited to the needs of Melissa; failure to properly adapt the bed selected to reduce risk given Melissa’s special needs and the inappropriate use of bumpers as a fall prevention device; failure to ensure important clinical information was retained regarding the adaption of the bed to ensure staff were fully informed of the specific needs of Melissa whilst a patient at the facility; inadequate training of staff and the lack of a proper process to respond to concerns by staff; the lack of involvement by the hospital of occupational therapists in the selection and use of appropriate beds for children with profound disabilities; and poor management practices relating to the development of internal policies and the training of staff regarding the admission and assessment of patients.
The Coroner also made recommendations to the Minister of Health to establish a group of appropriately qualified experts, in consultation with organisations that represent or care for children with physical and neurological disabilities, to develop a standard, guideline or other type of publication, which is directed to improving the safety of beds used by children with physical and/or neurological disabilities.