CHARLIE'S NOSEDIVE

CHARLIE’S NOSEDIVE

In his younger days Charlie Schriver had been a solidly built guy. He had worked for many years in construction where his natural strength was an asset. In his youth he had been a skilful amateur football player. He eventually met and dated Sarah. They kept each other company for two years until they married and together, they had two children. He was a nice guy. He was hard working and supportive of others. Everyone loved him. Family life was good.

A very unfortunate incident disrupted the life of their entire family when at the age of 60 Charlie collapsed at home with a right middle cerebral artery infarct – a stroke. It happened in the early hours one morning after he had climbed out of bed to visit the toilet and had collapsed on the bedroom floor. Because of his bulk Sarah was unable to assist Charlie back onto his feet. She called an ambulance which rushed him to hospital.

After coming home from hospital Charlie was a changed person. The stroke left him with paralysis on his left side and loss of balance. He suffered with left shoulder pain and problematic moods. The issues drastically affected his independence and caused Charlie to become frustrated.

Charlie was often impatient and agitated and at times aggressive. He complained that he was feeling increasingly irrelevant.

It eventually became difficult for Sarah to care for Charlie in their home.

After much deliberation the family ultimately decided that the best thing would be for Charlie to enter a residential care home. They arranged for him to take up residence at the Sunny Days Aged Care facility not far from the family home. Thirty-eight people lived at Sunny Days. Due to numerous medical and mental health conditions and incapacities the residents all needed high levels of care. Many suffered with dementia.

The staff at Sunny Days described Charlie as “challenging at some times and lovely at others.” But Sarah said he liked living there.

After Charlie had been living at Sunny Days for two years, he got out of bed very early one morning and climbed onto his motorised wheelchair without calling for assistance.

Nurse Signe Tornbloom and Patient Care Assistant Zach Levitt were in the corridor outside the rooms preparing the morning linen trolley for their residents rounds when they heard Charlie yelling for help. They ran down the corridor in the direction of the yelling and entered Charlie’s room. They could only see Charlie’s body from the shoulders down. He had slipped forward from his motorised wheelchair and was in a twisted position with his head lodged in the bottom drawer of his bedside storage set of drawers. Charlie’s head was face down jammed up below the middle drawer. Nurse Tornbloom could only see Charlie’s right cheek and his neck.

Charlie was yelling “get me out”, and “I can’t move, get me out”. Nurse Tornbloom tried to grasp Charlie by his shoulders but was unsuccessful because he was thrashing his right arm about trying to free himself. She called on Patient Care Assistant Levitt to bring the patient lifting machine but by the time the machine arrived at the room Nurse Tornbloom reassessed the risks of using the machine and told Levitt to leave the machine outside the room. Charlie was still yelling and thrashing about with his good arm on the right side of his body.

Nurse Tornbloom and Care Assistant Levitt tried to manoeuvre Charlie out from the drawer by grasping his shoulders, but they were unsuccessful because he was still lashing his arm about. Nurse Tornbloom checked Charlie’s mental state by asking him his age which he answered correctly. She observed he was breathing satisfactorily.

After six minutes of struggling to free Charlie from the drawer Nurse Tornbloom called triple zero emergency and requested an ambulance. She was advised by the emergency call responder not to move Charlie unless it was absolutely necessary and to watch Charlie closely to see if he became less conscious and to call back immediately if Charlie’s condition became worse.

Nurse Tornbloom then left Care Assistant Levitt to watch over Charlie while she waited outside for the ambulance and attended to issues regarding some of the other patients at Sunny Days.

Nurse Tornbloom returned to Charlie’s room several times between attending to the needs the other 37 odd patients at Sunny Days. She said later that Charlie was alert and breathing normally each time she returned to the room to check on him.

Twenty minutes after Nurse Tornbloom's initial call to emergency paramedics at the Northern ambulance station Gus Wezerek and Guillaume Kuskdjian received a code 2 – Ambulance required within 25 minutes at Sunny Days Aged Care. They arrived 40 minutes after the original call to emergency by Nurse Tornbloom. She received them at the entrance to the facility, directed them down the corridor and pointed out Charlie’s room. Care Assistant Levitt was standing at the entrance to Charlie’s room looking towards the Paramedics as they arrived.

Paramedic Wezerek saw Charlie lying with this head inside the drawer. His face was blue and there was no movement or sound from Charlie. He asked Care Assistant Levitt how long Charlie had been unconscious. She was unable to give a time frame, but she said she thought he had been asleep.

Paramedic Wezerek approached Charlie from behind and was able to lift his head out of the drawer. He rolled Charlie onto his back on the floor while his partner was bringing their equipment into the room. The paramedics commenced chest compressions and applied defibrillation pads. They attached an ECG monitor which identified that Charlie was pulseless. The paramedics used their portable radio to request further emergency assistance with regards to a cardio arrest situation.

The paramedics asked whether there was an Advanced Care Directive in place for Charlie. Nurse Tornbloom went to the office and checked Charlie’s file. She established that a Do Not Resuscitate directive was in place. The paramedics then stopped their resuscitation attempts in accordance with their operational guidelines. They radioed to cancel their request for further medical assistance and instead requested the attendance of the police.

Paramedic Wezerek said he believed that for all intents and purposes Charlie was deceased by the time he moved him from the drawer.

The paramedics later explained that they had been initially instructed to attend a patient who was mechanically stuck and not one who was unconscious. They said they would have brought more equipment if they had known Charlie was unconscious and the job would have been upgraded to urgent in the call coding so that they would have arrived earlier.

The Coroner’s report said that Charlie had died from asphyxiation.

Charlie’s wife Sarah said that the family were devastated at what happened to Charlie at Sunny Days. She said the Not For Resuscitation Order had been taken too literally and that in fact Charlie and the family did not mean it to apply to situations such as a fall where assistance could be rendered. She said that the family regarded Charlie’s death to be the outcome of a “bizarre accident” combined with a serious lack of management competence at Sunny Days.

Sarah said that an investigation by the Coroner had established that the management and staff at the Sunny Days facility did not have the requisite level of competence or expertise to manage an Aged Care Home of 38 residents.