Goodwin Ainslie aged care resident Ruth McKay died due to 'obvious, straightforward risk'

Ruth Alison McKay, 90, died at Canberra Hospital in January 2015, six days after staff at the Goodwin Ainslie aged care facility found her lying underneath an ornamental car in a secure courtyard.

In a decision published on Thursday, coroner Louise Taylor found doors leading from the secure memory support unit to an outside courtyard could be unlocked and opened without detection overnight.

The findings follow a coronial inquest, which started about five years after her death.

About 7.40am on January 17, 2015, staff at the aged care facility went to check on Mrs McKay, who had dementia, and found she was not in her room.

A short time later, they found Mrs McKay lying in her nightgown under a car in the memory support unit's secure courtyard.

When paramedics arrived Mrs McKay was conscious and alert on her back under the car with "substantial blood" nearby and a large haematoma to her left forehead.

She was taken to the hospital, where she died from pneumonia and a bacterial infection.

Ms Taylor found "there was no physical impediment to Mrs McKay gaining access to the outside courtyard area at any time of the day or night".

She said there were no outside door alarms or alerts to staff, Mrs McKay was independently mobile with a walker, and there had been no evidence "the task of unlocking and opening the door was physically beyond" the elderly woman.

"Goodwin's approach to ensuring the security of these doors relied entirely on staff compliance and intervention," Ms Taylor said.

"Even then, once locked by staff, the doors at the end of corridor could be unlocked, without detection, by any resident capable of turning the snib.

"The failure by Goodwin to adequately protect the safety and security of residents by ensuring that they were not able to access the courtyard through those doors, in particular at night, was a matter of public safety, and represented a risk to the residents.

"It was an obvious and straightforward risk of which Goodwin should have been aware. This failure led to Mrs McKay accessing the courtyard undetected and ultimately, to her death."

The coroner also found the woman had been outside in the courtyard for between two and three hours before she was discovered by staff.

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She said if the elderly woman's care plan had been followed, which included the use of room sensors, it would be likely Mrs McKay's absence would have been detected earlier.

However, Ms Taylor said Goodwin has "rectified this situation entirely by September 2020" by installing a timed automatic door and CCTV cameras.

"Mrs McKay was a beloved matriarch and it is clear that her death has been deeply felt by her family," she said.

"To reach 90 years of age is an extraordinary achievement and the circumstances of her death were a very unfortunate end to a rich life, well lived."

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