Preventable Tragedy: Dementia Patient’s Death at Gold Coast Hospital Highlights Systemic Failures
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A coronial inquest has revealed a fatal assault at a Gold Coast hospital could have been avoided if adequate security measures had been in place for a patient with a history of violent behavior. The incident,which occurred in October 2023,resulted in the death of a former Gold Coast police officer and raises serious questions about the suitability of a hospital unit for patients with severe dementia.
Former Officer Dies After Assault
Kevin Farr, 61, succumbed to a brain bleed after being punched in the head by Robert Hunter, 77, while a patient at Robina Hospital’s complex management unit. The attack unfolded on october 8, 2023, after Hunter entered Farr’s room. According to testimony, Farr verbally challenged Hunter, and within seconds, the door to the room was slammed shut, concealing the escalating violence. By the time staff gained entry approximately one minute later, Farr was on the floor, and Hunter displayed signs of injury to his hand.
Unit Not Designed for Severe Dementia, official Admits
The 20-bed complex management unit, established in 2021, was originally intended for patients awaiting discharge with complex psychosocial and functional needs.However, Deborah Corry, the nurse manager for the unit, conceded during the inquest that it had increasingly become a de facto ward for individuals with severe dementia by 2023. She stated it was common to encounter patients experiencing delusions, hallucinations, and confusion wandering the hallways.
History of Violence Ignored
Crucially, Hunter had a documented history of “code black” incidents – denoting violent behavior toward other patients – yet was not assigned a dedicated security guard on the day of the assault. While guards were typically assigned immediately following a code black event, this protection was not consistently maintained. This lapse in security is central to the inquest’s investigation into the circumstances surrounding Farr’s death.
Inexperienced Nurse faced with Challenging Situation
The nurse tasked with providing one-on-one care for Hunter that morning had never previously worked in a dementia ward and was on her fourth shift at the hospital.Despite possessing 22 years of nursing experience, Miranda Irwin testified that she struggled to manage Hunter’s behavior, noting he repeatedly wandered into other patients’ rooms. Irwin described feeling “tossed in the deep end without proper help and assistance,” stating,”I did the absolute best of my ability with this patient.” She further emphasized that she felt powerless to prevent the incident, stating she was not physically capable of controlling Hunter and that a male nurse or additional security would have been more appropriate.
Critical Safety Recommendations Unheeded
Corry revealed that she had previously recommended the installation of anti-barricade doors – standard in the hospital’s mental health unit – to prevent similar incidents. However, these doors had not been implemented at the time of the assault.
Both Patients Tragically Pass Away
A murder investigation was initially launched, but ultimately discontinued after Hunter was deemed to lack the capacity to be held criminally responsible. his condition deteriorated rapidly, and he died approximately one month after the incident.Farr’s death has prompted a review of patient safety protocols at Robina Hospital.
New Cognitive Unit Aims to Prevent Future Incidents
A dedicated acute cognitive care unit is scheduled to open at the Gold Coast University Hospital this month. Hospital officials believe this new unit will reduce the number of patients with severe dementia being admitted to the Robina complex management unit, thereby mitigating the risk of similar tragedies. Corry stated that the new unit would mean patients with severe dementia were “less likely to end up” in the Robina unit, and the risk of a similar incident occurring there again was “unlikely.”
The inquest continues on Tuesday, with further testimony expected to shed light on the systemic issues that contributed to this preventable death.
