An aged-care resident with Alzheimer's disease died of heatstroke after being alone in an unshaded area in summer due to a lack of staff safety checks, a coroner has found.
Queensland Coroner Carol Lee last week released non-inquest findings into the 85-year-old man's death in hospital after suffering fatal heat injuries at a regional residential aged care facility.
"At approximately 12:18pm on February 11, 2023, the resident was located unconscious in an unsheltered patio area at the facility. He was found on the concrete in the sun and was noted to be hot to touch," Ms Lee said.
The resident, who used a wheelchair for mobility, was last seen at 10am that day.
On arrival at hospital, he appeared to have suffered burns and his temperature was more than half a degree higher than the 40C threshold for the start of heat-related illness. The man died in hospital a week later.
The federal Aged Care Quality and Safety Commission held a serious incident investigation into the death, which found the resident moved himself to a garden patio area in a position that was not easily visible to those inside the building.
"He remained in this area for two hours and eighteen minutes. The area had no shade, on the day of the incident the temperature was approximately 30C, and the resident had no sun protection except for the clothes that he wore," the investigation report stated.
An assistant nursing staff member had been meant to physically sight and record the resident's location every hour to confirm his safety and location.
Ms Lee said the resident had a "very determined manner" and staff respected his choices to not partake in some care activities and move about the facility in his self-propelled wheelchair.
On the day of his heat injuries the resident's location was not checked for more than two hours and 20 minutes.
A registered nurse began to search for the resident at 12pm to provide him with his regular medication.
The aged-care facility said it had improved staff education and allocated another person to double-check residents' locations were being sighted and recorded.
The facility has also installed alarms on doors to the outside gardens.
"This tragedy was preventable and occurred in the context of staff failure to undertake periodic visual safety and wellbeing checks," Ms Lee said.
Ms Lee said she was satisfied the facility had taken steps to prevent a similar incident in future.
"The staff member who failed to undertake the critical sight observations has been terminated and has been the subject of a mandatory report to the Office of the Health Ombudsman," Ms Lee said.
