Coroner's Finding: Standaloft, Cora Gwendoline

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Record of Investigation into Death (Without Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Simon Cooper, Coroner, having investigated the death of Cora Gwendoline Standaloft Find, pursuant to Section 28(1) of the Coroners Act 1995, that: a) The identity of the deceased is Cora Gwendoline Standaloft; b) Mrs Standaloft died as a result of injuries sustained in an unwitnessed mechanical fall at a nursing home; c) The cause of Mrs Standaloft’s death was pneumonia due to traumatic left rib fractures, complicated by malignant left pleural effusion with recent lung carcinoma; and d) Mrs Standaloft died on 1 January 2019 at 360 Hobart Road, Youngtown, Tasmania.

In making the above findings I have had regard to the evidence gained in the comprehensive investigation into the death of Mrs Standaloft. The evidence comprises:  Police Report of Death for the Coroner;  An affidavit of Mrs Standaloft’s son, Robert Dyble;  An affidavit of Mrs Standaloft’s daughter, Beverly Palmer;  The opinion of a pathologist;  Ambulance Tasmania Records;  Medical Records – Tasmanian Health Service;  Medical Records – Prospect Medical Centre;  Records – Glenara Lakes Nursing Home;  Medical Imaging Reports;  Relevant police and witness affidavits (including nursing home staff); and  A report from the medical advisor to the Coroner’s Office.

Background Cora Gwendoline Standaloft was born Cora Gwendoline Ames in Melbourne on 20 July 1923.

A retired office worker, she was aged 94 years, widowed with two children and living at Glenara Lakes Nursing Home at the time of her death.

Mrs Standaloft grew up in Clifton Hills, Melbourne. In 1940 she married Stanley Dyble and had two children. The couple separated in 1955 and she moved to Launceston. In 1972 she married Athol Standaloft and lived with him until he passed away in 2008.

Mrs Standaloft suffered from emphysema, after being a heavy smoker up to the age of 50 years.

In 2013, she was diagnosed with lung cancer and became a resident at the independent living facility of Ainsley Southern Cross Care. Her cancer was successfully treated. Later in 2013, she had an unwitnessed fall at the facility after falling in the shower. She suffered fractures of a rib and her hip and moved to Glenara Lakes Nursing Home as a result.

Mrs Standaloft had other medical complaints including osteoporosis, thyroid issues, moderate dementia, depression, anxiety, glaucoma, and senile tremor, loss of hearing, diverticular disease, and haemoptysis, amongst others. Her last appointment with her local GP was on 20 December 2018 was for regular review.

On 26 October 2018, Mrs Standaloft had an unwitnessed fall at the home. She fell from a chair and fractured her left ankle. She seems to have made a fair recovery from this fall.

Circumstances Surrounding Death On 31 December 2018, at about 2.00pm, Mrs Standaloft was found next to her chair in her room on the floor. Later that evening, the evidence is she became unsettled and confused asking staff where her deceased husband Athol was. She was taken to the home’s office and called her daughter. During the call, Mrs Standaloft told Beverly that she was the only resident in the nursing home. The telephone call lasted for 30 minutes, after which Mrs Standaloft appeared settled and went to bed.

Nursing home records show she was checked at 12.30am on 1 January 2019 and again at 2.19am.

At 6.05am, a staff member responding to a movement alert in another room heard Mrs Standaloft call out. Mrs Standaloft was found on the floor near her bed and told the staff member that she had needed to go to the toilet and had fallen from the bed. The movement alert in her room had not been activated.

Mrs Standaloft complained of pain in her left shoulder area and was holding her ribs. She was taken by Tasmania Ambulance to the Launceston General Hospital where she was admitted.

After consultation with family, due to her condition and age, a decision was made to care for her palliatively. I note that this decision was in accordance with Mrs Standaloft’s end of life care plan. Accordingly, it was arranged for her to be returned to Glenara Lakes Nursing Home for

further palliative care. Prior to transport, she became unconscious. She was returned to the Home and died there at about 10.30pm the same day.

Investigation The fact of Mrs Standaloft’s death was reported in accordance with the requirements of the Coroners Act 1995. After formal identification, her body was transported to the mortuary at the Launceston General Hospital. At the mortuary, a pathologist, Dr Rosanne Devadas examined her body and reviewed her medical records. Dr Devadas expressed the opinion, which I accept, that the cause of Mrs Standaloft’s death was pneumonia due to traumatic left rib fractures complicated by a malignant left pleural effusion with recurrent lung carcinoma. I am satisfied that the unwitnessed fall at the nursing home was, at the very least, a contributing factor to Mrs Standaloft’s death although other comorbidities contributed to her passing.

The circumstances of Mrs Standaloft’s death, and in particular the management of her at the nursing home, was reviewed for me by Dr Anthony J Bell MB BS MD FRACP FCICM, medical advisor to the Coroners Office. Dr Bell expressed the opinion that the care provided was of good standard.

Conclusion I am satisfied from the police investigation that there are no suspicious circumstances surrounding Mrs Standaloft’s death and that no other person was involved in her death.

Nonetheless, a manner of significant concern is the fact that Mrs Standaloft’s bed or movement alarm did not work. I note her records at the nursing home indicate that the alarm needed to be tested but the records contain no indication that such testing ever occurred.

I accept that the failure of the bed alarm to activate did not cause Mrs Standaloft’s death - however it is likely to have led to a delay in her receiving essential medical treatment.

Comments and Recommendations The circumstances of Mrs Standaloft’s death satisfy me that it is appropriate to comment that it is essential that bed alarms in nursing homes are regularly tested.

I convey my sincere condolences to Cora Gwendoline Standaloft’s family and loved ones.

Dated 1 April 2020 at Hobart in the State of Tasmania.

Simon Cooper Coroner