Bludgeoned in bed: ‘Unable to escape’
A WOMAN who was bludgeoned to death as she slept in bed was 'unable to escape' as the attacker beat her with a chain, a court has heard.
South Australian coroner Mark Johns this morning handed down his findings into the death of Adelaide nursing home resident Dorothy Mavis Baum who was killed by an elderly dementia patient at St Basil's Aegean Village in Christies Downs, on May 30, 2012.
Rozalia Setalo, 85, hit Ms Baum, 93, with a plastic-covered chain containing metal magnets and was found in her bed with wounds to her arms and face so deep they revealed bone.
Ms Baum died in Flinders Medical Centre the following day.
In his findings on Thursday, Mr Johns said there was a "gross dereliction of proper management" by two nursing home staff members who barricaded themselves in the nurses' station during the attack.
The court heard that Ms Setalo also punched and threw items at staff and used her walking frame to hit them before eventually being subdued. No charges have been laid against Ms Setalo.
Mr Johns said carer Harit Kamal and registered nurse Ute Latz were duty bound to expose themselves to a risk of being attacked because a failure to do so might expose far more vulnerable people to injury.
"That risk was not merely theoretical because Ms Setalo clearly attacked and grievously injured Mrs Baum while the latter was helpless in her bed and unable to escape," the coroner said.
"Mrs Baum no doubt would have been terrified during this attack. "The situation is made even worse by the fact that for at least two hours and probably longer, Mrs Baum was left bleeding.
"She was lying in her bed in her own blood."
The coroner said both nurse Ms Latz and Mr Kamal believed Mrs Baum's injuries were self-inflicted which compromised a proper investigation into her death. He said he also found it "entirely inadequate" that those managing the nursing home escaped any sanction.
Ms Latz, who was on duty on the night Mrs Baum was attacked, gave evidence in the Coroner's Court, admitting to a series of procedural errors relating to the handling of Ms Setalo's violent outburst and the discovery of the badly injured Mrs Baum.
The court had previously heard that Mrs Baum had lay dying in her bed for up to three hours before she was found in a pool of blood.
Ms Latz said she understood the nursing home's policy required her to confine violent residents and move other residents and staff away from the aggressor but did not do this.
"There wasn't anywhere I could have confined her safely," she said.
Asked why she didn't check on residents once Ms Setalo had been subdued, Ms Latz said: "It didn't enter my mind".
The court also heard that when Ms Latz called an ambulance after discovering Mrs Baum with severe injuries she was given the option of having paramedics arrive within an hour or 15 minutes, and chose the former.
When questioned as to why she did not ask for a quicker response, given Mrs Baum had been "torn to shreds," she said: "I don't know."
The coroner this morning said he hoped that operational changes introduced to the Commonwealth Aged Care Framework in 2018 would ensure a greater level of accountability in the senior management and governing boards of nursing homes such as St Basil's. The coroner called for them to be subjected to a system of personal accountability when standards of care were not met.
"Only by adopting a scheme in which there is some personal risk to those involved in the management of aged care providers at the highest level could the public be confident that an event such as the appalling treatment of Mrs Baum in life and then in death could not happen again," Mr Johns said.
- With AAP