The NSW Deputy State Coroner hopes the lessons learned from the death of Carney Schultz in a Figtree group home will help improve disability care across Australia.
The 28-year-old woman, who was born with severe intellectual and physical disabilities, was found dead in her bed by her carers at the Outlook Drive home on April 21, 2015.
She died five hours after suffering an eight-minute epileptic seizure, but an autopsy could not determine the cause of death.
A staff member not trained to administer Ms Schultz’s seizure medication, midazolam, had been working a solo shift that morning.
The worker attended to her until she recovered from the seizure, but the protocol to call an ambulance if the seizure continued past five minutes was not followed.
Two workers who started their shifts later that morning both saw Ms Schultz alive – at 6am and 8.20am. Then at 8.50am she was found facedown in her pillow, her face blue.
Despite CPR by staff, and then paramedics, she could not be revived.
In inquest findings into the death released on Friday, Magistrate Derek Lee determined that Ms Schultz died due to complications of epilepsy.
However he also found that training of disability support workers (DSW) by the Department of Family and Community Services (FACS) – who ran the home at the time – was “less than optimal”.
“Whilst the evidence establishes that an overall good quality of care was generally provided to Carney, deficiencies in training meant that there was the possibility of adverse outcomes,” he stated.
“It also appears that casual DSWs were not afforded the same training opportunities as full-time staff, in particular in relation to administration of midazolam.
“This (led) to potentially unsafe care practice where staff untrained in the administration … were rostered by themselves on night shifts, a period during which it was well known that Carney frequently experienced seizures.”
Magistrate Lee also found that a number of documents relevant to the management of Ms Schultz’s epilepsy appeared to contain inconsistencies.
He noted that since the 2015 death, FACS had implemented changes in the Illawarra and Shoalhaven which had led to an improvement in care for group home residents, particularly those with epilepsy.
Training in the administration of midazolam was now mandatory for all staff working with clients requiring the medication, while steps had also been taken to ensure they fully understood the individual needs of their clients.
However Magistrate Lee also noted that most state-run group homes had transitioned to the non-government sector under the National Disability Insurance Scheme (NDIS). The Figtree home, for instance, is now run by The House With No Steps.
“Whilst disability service providers in the non-government sector might duplicate systems, procedures and protocols, that have been implemented by FACS, they are not required to do so and may well develop their own systems,” he said.
“If this is the case then the lessons learned from Carney’s death can only serve to inform those responsible now, and in the future, for overall oversight to ensure that other clients who suffer from epilepsy are provided with adequate and appropriate care.”
Magistrate Lee subsequently recommended that a copy of his findings be sent to the chief executive officer of the National Disability Insurance Agency and to the managing director of the House With No Steps.
“… so that consideration can be given to the identified shortcomings in the supported living services provided to Carney, and the lessons learned and improvements made as a result of her death,” he stated.
He also recommended that a multi-disciplinary team approach be taken to the drafting, and implementation, of epilepsy management plans by group home disability service providers in the region.
Magistrate Lee passed on his condolences to the family, including Ms Schultz’s mother Gail and sisters Kelsey and Teagan.
“Throughout her life Carney constantly showed her remarkable resilience and proved time and again that she was a fighter,” he said. “There is no doubt that her spirit will always remain with her mother and her sisters.”