• The Communiqués

Residential Aged Care Communiqué Volume 16 Issue 4 November 2021

Download PDF: RAC Communiqué November 2021


In this edition

  • Editorial

  • Case: Managing poisoning, maintaining poise

  • Expert Commentary: We have seen it all before

  • Resource: Poisons Information Centre

  • Preventing Unwanted Sexual Behaviour in Aged Care

  • Communiqué Podcasts

  • COVID-19 Publications from Health Law and Ageing Research Unit

Welcome to the final edition of the RAC Communiqué for 2021. It’s been another challenging and busy year with the emphasis on implementation of the national COVID-19 vaccination program to protect our residents and each other. With the understandable saturation coverage of the pandemic for the past two years, we have chosen to shift our focus towards a topic that is not often addressed but is a significant clinical risk causing residents to become hospitalised or die.


For those subscribers who are keen on learning more about COVID-19 and aged care we have provided a list of peer review academic articles from our team’s research program. These include studies describing the COVID-19 outbreaks in Victoria, Australia and models for risk management during a disaster response. We will continue to monitor the coroner’s courts of New South Wales and Victoria which will be holding inquests into the residential aged care COVID-19 outbreaks in their jurisdictions.


In this edition, we present a case with a wide range of professional, organisational, and environmental risks. The death of a resident from inadvertent poisoning illustrates the interconnectedness of the multiple components that are needed to successfully operate a residential aged care service.


The case encompasses the supply and storage of chemical agents, the roles and intersection of the clinical, personal care and domestic staff, emergency management response, verbal and written communication.


Poise is one of the professional characteristics needed when managing any emergency, a state of being balanced, level-headed and calm are essential to assessing a situation, gathering the necessary information and responding quickly.


I have taken the liberty of writing the commentary “We have seen it all before” to highlight that there was nothing that should have been surprising about this case. By recognising the vulnerabilities in our organisation we could be proactive in risk assessments to keep those in our care safer. The other interesting aspect of the case is how clearly the methods for injury prevention are applied to the medicolegal investigation into this death. The commentary draws on cases and expert commentaries from our library of Residential Aged Care Communiqués issues reinforcing we have seen it all before.

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