A Hobart aged care facility received an alert about the dangers of bed poles more than nine months before an elderly resident became trapped and suffocated, a coroner says.
Barbara Westcott, 84, died in March 2012 at South Hobart's Vaucluse Gardens and was found kneeling on the floor beside her bed with her neck and head jammed between the mattress and pole, which is designed as a mobility device.
"Over nine months before Mrs Westcott's death, a South Australian coronial finding warning of the dangers of entrapment and asphyxiation in bed poles had come to the attention of Vaucluse Gardens," coroner Olivia McTaggart noted in her findings published on Thursday.
The Department of Health and Ageing email outlined the circumstances in which bed poles should not be used.
"The evidence available before the commencement of the inquest did not satisfactorily answer the question as to when or why Mrs Westcott's bed pole was installed, the reason it remained installed or the response by Vaucluse Gardens to the alert," Ms McTaggart noted.
Despite the alert being circulated to some staff and a recognition that Vaucluse Gardens had some of the questionable models in use, Mrs Westcott's bed poles were not removed.
"I categorise the failure to detect, assess and remove Mrs Westcott's bed pole as a failure of the highest magnitude," the coroner said.
"There was a collective and ongoing failure of individuals and processes to effect proper action to eliminate the risk.
"There were multiple, obvious opportunities to take action that could have prevented Mrs Westcott's death."
The coroner recommended care facilities immediately cease using the KA524 model bed pole and that the federal government send an Australia-wide alert warning of the risks.
She also recommended staffing and qualification changes at Vaucluse Gardens.
