Coroner's Finding: Zito, Adelina

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Record of Investigation into Death (Without Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Leigh Mackey, Coroner, having investigated the death of Adelina Zito Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is Adelina Zito; b) Ms Zito died in the circumstance I set out below in these findings; c) Ms Zito’s cause of death was acute limb ischaemia; and d) Ms Zito died on 3 August 2022 at Hobart, Tasmania.

In making the above findings I have had regard to the evidence gained in the investigation into Ms Zito’s death. The evidence includes:

• Police Report of Death for the Coroner;

• Hospital Report of Death to the Coroner;

• Records of OneCare, Barossa Park Lodge;

• OneCare’s response to falls questionnaire;

• OneCare’s letter to the Magistrates Court – Coronial Division of Tasmania dated 16 November 2023 and enclosures;

• Tasmanian Health Service medical records;

• Opinion of Dr Anthony Bell (MD FRACP FCICM), Coronial Medical Consultant;

• Opinion of Dr Andrew Reid, Forensic Pathologist;

• Opinions of Kevin Egan, Coronial Nurse; and

• Affidavit of John Zito sworn 27 August 2023.

Adelina Zito Adelina was born on 21 January 1929 and was 93 years of age at the time of her death. She was born and raised in Petina, a small village in Southern Italy. She was the last surviving of her six siblings and a widow when she died. She had little formal education having grown up

under the cloud of the Second World War. Her primary language was Italian, and she was able to communicate in English but was essentially illiterate.

Adelina was raised in the Catholic faith, and she retained that faith throughout her life. At age 24 she married her husband and together they raised their three children, Tony, John and Concetta. The family migrated to Tasmania in 1951.

During her life Adelina worked in silk and textiles, sewing sheets and pillowcases. She lived in her own home, until moving into a nursing home in 2021. She was well supported by her adult children. Her sons Tony and John, who both lived locally, regularly visited her. Her daughter, who had moved to mainland Australia, was in regular telephone contact.

An “Aged Care Assessment”, conducted by an Aged Care Assessment Team (ACAT) was undertaken on 2 August 2019 which noted Adelina to be “very independent”.1 Her children supported her with transport, home maintenance tasks and the provision of cooked meals.

She enjoyed trips into the city and had friends who would visit her in her home. She also had the assistance of a home care package but at times would limit or refuse assistance.

Adelina suffered some health issues including congestive cardiac failure necessitating the insertion of a pacemaker, chronic kidney disease, hypertension, atrial fibrillations, bilateral hip replacements, iron deficiency anaemia and cognitive impairment. She experienced pain at times. She appears, however, to have been resolute in her belief of her own independence.

On 14 July 2021, Adelina became a resident at Barossa Park Lodge, a Residential Aged Care Facility (RACF) operated by OneCare. She moved to the RACF due to concerns that she no longer had a capacity for independent living following hospital admissions in 2021. Records of the RACF reflect an appropriate level of care was provided to Adelina during her residency there.

In a 19 May 2022 “Aged Care and Service Plan Review” conducted by the RACF with Adelina’s son John, the feedback given was positive, the RACF were meeting expectations and no actions were required of them.2 An evaluation conducted with Adelina at the same time was also positive with her only complaint relating to the standard of food provided and a failure to have carried through on a promise to let her go into the kitchen and teach the chef at the facility how to cook Italian food.3 1 ACAT Assessment 2 August 2019.

2 RACF Aged Care and Service Plan Review dated 19 May 2022.

3 RACF Consumer Evaluation dated 19 May 2022.

Pain On admission to the RACF, Adelina reported experiencing intermittent pain to her neck and mid back, aggravated by movement. She was provided with a pain management plan. On 13 August 2021, a care directive required an allied health professional to give her a therapeutic soft tissue massage to her neck and/or lower back for a minimum of four times per week, for pain management.4 On 19 May 2022, a further care directive required provision of therapeutic massage to Adelina’s wrists/hands at least weekly also for pain management.5 On 15 July 2022 in a “Consumer of the Day Review” Adelina agreed that her pain was being managed by the RACF as per her care and services plan.

Adelina was unable to access her “Pain Management Program” during the weeks ending 22 and 29 July 2022 due to a “covid19 risk management process” then operating at the RACF. It is noted that “alternate strategies were implemented”.6 What strategies were in fact implemented are not apparent from the records.

General Practitioner Services at the RACF The services of a general practitioner were provided to Adelina whilst she was a resident of the RACF through Access Aged Care (AAC). AAC provided on-site visits by general practitioners at the RACF “strictly” once a week.7 If more urgent medical attendance was needed a locum appointment could be requested by staff from AAC or the Hello Home Doctor Service or Ambulance Tasmania (AT) could be requested to attend.8 The AAC guidelines on how to request urgent medical review were set out in a document and an email sent to the RACF.9 Those guidelines were:

• Dr Shaw will be at the RACF on Tuesdays for resident reviews and appointments are to be made by emailing a request to AAC;

• For review on days other than a Tuesday AAC must be sent an email with the request and a full clinical assessment of the resident must have been undertaken by a registered nurse prior to escalation to the AAC. The RACF must advise if 4 RACF Other Complex Health Care Directive dated 13 August 2021.

5 RACF Other Complex Health Care Directive dated 19 May 2022.

6 RACF notes 29 July 2022 and 22 July 2022.

7 Email: Ruth Hunt-Brown AAC to Nicolle Ferry, Barossa Park Lodge RNs and Barossa Park Lodge Ens dated 29 July 2022.

8 Email: Ruth Hunt-Brown AAC to Nicolle Ferry, Barossa Park Lodge RNs and Barossa Park Lodge Ens dated 29 July 2022.

9 AAC “GP requests, notification and escalation” and email: Ruth Hunt-Brown AAC to Nicolle Ferry, Barossa Park Lodge RNs and Barossa Park Lodge Ens dated 29 July 2022.

the review is required as soon as possible or can wait until the next usual general practitioner round;

• Dr Shaw was not available for on call visits; and

• If the request for review is urgent and AAC cannot be reached the request needed to be referred to the Hello Home Doctor Service.

Adelina was attended to by Dr Shaw at the RACF. In the period leading up to her death the “GP review notes” kept by the RACF reveal she had a consultation on 3 May 2022 for prescription and management of her chronic kidney disease. At that time, she was in isolation with COVID-19. She saw Dr Shaw on 10 May 2022 for pain management, on 7 June 2022 for shortness of breath and again on 21 June 2022 for shortness of breath as well as dry eyes. The first consultation regarding leg/knee pain was on 2 August 2022. There is no record of a consultation with Dr Shaw between 21 June 2022 and 2 August 2022. However, inconsistency in the records leaves open the possibility that there was a consultation during this period. I consider this and the 2 August 2022 consultation in more detail later in these findings.

The escalation policy The RACF have a policy and procedure document to guide staff on the recognition of deteriorating residents and the escalation of their care.10 The document provided by the RACF is reviewed biennially, its last review occurring in July 2023. I have not sighted the document in the form that it existed in July/August 2022. Given that the document is reviewed every second year and that a review of the document occurred in July 2023 there is a reasonable basis to infer that the escalation policy existed at the relevant time, however the 2023 review may have resulted in some changes to it.

The document clearly articulates the policy of the RACF to ensure staff are sufficiently trained to recognise and respond to changes in a resident’s condition so that appropriate care is provided in a timely way and that the “early recognition and escalation of deterioration can reduce the risk of further deterioration thus reducing morbidity and mortality incidents”.11 Mechanisms identified that assist in the recognition of deterioration include the “measurement and documentation of observations” and “consulting with the consumer…and representatives as relevant”.12 As I comment later in these findings there was a lack of vascular observations either undertaken or at least recorded in Adelina’s case and a failure to have escalated her care in a timely manner.

10 Recognising Deterioration and Escalation of Services dated reviewed July 2023.

11 Recognising Deterioration and Escalation of Services dated reviewed July 2023, page 3.

12 Recognising Deterioration and Escalation of Services dated reviewed July 2023, page 3.

The falls Shortly prior to her death and proximate to her developing pain and coldness in her right lower limb Adelina fell at the RACF on 20 July 2022, 30 July 2022 and 1 August 2022.

On 20 July 2022 an incident report records that Adelina fell the previous night. The circumstances of the fall are unknown. It was not witnessed. Other than a small blister on her “second left toe”, no injuries were found.

On 30 July 2022 Adelina again fell. An incident report states that Adelina had been found on the floor of her room, she was reviewed by a nurse and assisted into her bed. She was found to have old bruising to her right inner ankle, otherwise there were no apparent injuries.13 Adelina advised the staff that she had fallen in the bathroom and then crawled to the bedroom.14 The incident report in respect of the 1 August 2022 fall describes Adelina sitting on her bottom next to her bed at 6.58pm. She described having slipped from the bed landing on the floor. No injury was suffered.15 The records of the RACF have been reviewed by Mr Kevin Egan (RN, Crit Care Cert, MApplMgt (Nursing)), Forensic Coronial Nurse.16 On the basis of that review he has concluded that the falls prevention strategies and assessments of the RACF were comprehensive and appropriate. I agree with this assessment.

There is no evidence of Adelina having suffered a significant injury in any of the falls nor any evidence that any one or combination of the falls caused ischemia of Adelina’s right leg albeit that the ischemic limb may have contributed to the falls of 30 July 2022 and/or 1 August 2022 occurring. I find accordingly that the falls were not causative of Adelina’s right lower limb symptoms, ischemia, or her death.

The events leading up to Adelina’s death From 15 July 2022 to 2 August 2022 the RACF was in lockdown because of an outbreak of

COVID-19.

Adelina commenced to experience pain in her right leg, distal to the knee. When this pain commenced is unclear but is likely to have had its onset around 26 to 28 July 2022.

13 RACF Incident report 30 July 2022.

14 RACF Incident report 30 July 2022.

15 RACF Incident report 1 August 2022.

16 Report Mr Egan dated 10 October 2023.

The evidence of John, and through him, his sister Concetta, was of frequent contact between each of them, the RACF and Adelina regarding Adelina’s complaints of pain in her right lower limb from 28 July 2022. John recalls being advised by a nurse at the RACF that Adelina was being monitored, she had been provided pain relief and her leg massaged.17 An examination of the right lower limb was likely conducted following Adelina’s 20 July 2022 fall and certainly undertaken following the 30 July 2022 fall noting the observation of old bruising to the right ankle at that time and a record of neurological observations being undertaken between 30 July 2022 and 2 August 2022 of the right lower limb. These observations were of the strength and power of the bilateral lower limbs and demonstrated no change in power bilaterally on 30 and 31 July 2022, and a mild decrease in power of the right leg on 1 and 2 August 2022. The records do not reflect that there were any neurovascular observations done of the right leg at this time.

The RACF monitored Adelina’s pain and recorded the outcome of that monitoring on a “Pain Flow Chart”. The Pain Flow Chart was part of Adelina’s pain management at the RACF and was directed toward hip pain, lower back pain, bilateral hands/wrists pain, neck pain, bilateral knee pain and post fall pain. Pain assessments were conducted on 31 July 2022 and 1 August 2022. All pain ratings were at level 1 excluding a pain rating at level 4 on 1 August 2022 regarding the bilateral knees. It is, however, unclear if pain assessments were in fact conducted on 1 August 2022 as Adelina is described as “sleeping”. The pain rating at 4 relating to the bilateral knees was also made at this time and on that basis, I think it reasonable to infer that the pain assessments were done however the experience of pain was insufficient to waken Adelina until the assessment of her knees. The pain ratings on these assessments, however, appear inconsistent with the progress records of the RACF which describes ongoing pain to the right lower limb and the actions of Adelina in requesting hospital transfer and seeking family assistance during this period.

The experience of pain by Adelina at the RACF was also recorded on “PainChek”. This document recorded that Adelina experienced an escalated level of pain from at least 30 July 2022, described as “moderate” to 1 August 2022 and causing “abnormal sitting/standing” on 2 August 2022.18 Progress notes kept by the RACF record that Adelina complained of right leg/knee pain on 28 July 2022 for which paracetamol was given with moderate effect.19 The leg/knee pain continued with ongoing complaints recorded on 28 July 2022, 30 July 2022 and ongoing 17 Affidavit John Zito sworn 27 October 2023.

18 PainChek record.

19 RACF progress notes 11.07am 28 July 2022.

without evidence of any substantive response to the complaint by the staff of the RACF other than the provision of paracetamol, which was ineffective.

On 31 July 2022 the notes refer to John calling the RACF at 6.05am after having been called by Adelina five to six times in half an hour about her pain. She was given paracetamol and John’s request for medical assessment was noted.20 On 31 July 2022 the complaint of leg pain continued. Adelina is described in the RACF notes as wanting a “needle on her leg” and asked if the leg could be wrapped with cloths and covered with a blanket.21 Later in the day the notes record Adelina requesting to go to the hospital twice. The first occasion was subject of a case note timed 2.16pm22 and the second in a case note timed 5.09pm.23 On the second occasion she is described as “adamant” for hospital transfer.24 Close to 4.00pm on 31 July 2022 the RACF sent an email to AAC advising of Adelina’s complaints of leg/knee pain, that Panadol wasn’t helping, she was requesting to go to hospital and asking for AAC to arrange a review “as soon as possible”.25 This is the first occasion at which the RACF sought to escalate the care of Adelina. By requesting the review to be “as soon as possible” and in line with the guidelines for AAC, RACF staff were seeking medical review to occur on 31 July 2022 or 1 August 2022 at the latest and before the usual site visit of the general practitioner on 2 August 2022. The medical review of Adelina did not occur until 2 August 2022. This reflects a failure of the AAC to, in accordance with its own guidelines, arrange for an urgent on-site visit by a medical practitioner for Adelina’s review following the RACF’s request and a failure of the RACF to continue to seek urgent onsite medical assistance from AAC, Hello Home Doctor Service or AT given the failure of AAC to respond in a timely manner to the requested assistance.

On the evening of 31 July 2022 Adelina is described in the notes as “settled” and reassurance given that she would be reviewed by a doctor as soon as possible.26 This review did not occur until 2 August 2022 despite the continuation of symptoms, the requests of Adelina and her family for medical assistance and the recognition of the need for a medical review as soon as possible as reflected in the email from the RACF to AAC earlier that day.

A registered nurse at the RACF reviewed Adelina in the early hours of 1 August 2022. The leg pain was noted to be continuing without clinical signs of a cause for it being evident.27 20 RACF progress notes 8.15am 31 July 2022.

21 RACF progress notes 7.06am 31 July 2022.

22 RACF progress notes 2.16pm 31 July 2022.

23 RACF progress notes 5.09pm 31 July 2022.

24 RACF progress notes 5.09pm 31 July 2022.

25 Email: Clare King to AAC 31 July 2022, email IT support to Nicolle Ferry OneCare dated 20 November 2023 and RACF progress notes 5.09pm 31 July 2022.

26 RACF progress notes 9.03pm 31 July 2022.

27 RACF progress notes 4.10am 01 August 2022.

The note suggests that an examination of the leg was conducted at that time. The form of that examination, whether it included the vascular supply to the leg and its outcome, is not disclosed in the notes.

Adelina was reviewed at 11.19am on 2 August 2022 by an occupational therapist at the RACF. At that time, she complained of right leg pain and declined to weight bear. The record states the complaints to have been ongoing “1/15” ago (later corrected to “1/52”).28 This reflects that Adelina had been experiencing pain in her leg for one week up to 2 August 2022 consistent with Adelina experiencing the pain at least by 26 July 2022. The notes of the review by the occupational therapist on 2 August 2022 refer to Adelina as not being able to describe her pain “well” and that it was a “cold pain”, she was short of breath, her voice was weak, she was cold and had difficult standing and mobilising.29 A report of Adelina’s condition was reportedly made by the RACF’s Occupational Therapist to the enrolled nurse, and it was agreed that Adelina was in need of “General Practitioner Review”. There is no record, despite Adelina’s symptoms, of a circulatory or sensory assessment then being conducted on the leg, or it being visualised, or the colour and temperature of the limb being assessed.

Adelina was finally reviewed by a general practitioner, Dr Shaw, on 2 August 2022. The notes kept by the RACF of that review are confusing. The first note of the attendance (entry timed 4.05pm) refers to Adelina being transferred to hospital. The second (entry timed 5.12pm) records Adelina to have “increased knee pain”, “only on Panadol” and for review the following week. The third (entry timed 5.47pm) records that Adelina had been seen by the doctor and it was queried as to if she had a deep vein thrombosis in the right lower leg.

She was for transfer to the Royal Hobart Hospital (RHH) which occurred at approximately 4.45pm. Dr Shaw’s referral letter to the RHH emergency department states that Adelina’s right lower limb was “swollen” and “pulseless”.30 The second entry does not sit comfortably as a record of a consultation with Adelina on 2 August 2022 given her level of symptoms at that time and the decision made by Dr Shaw for her transfer to hospital on that day. The possibility exists that this consultation has been incorrectly recorded as occurring on 2 August 2022 but in fact occurred at an earlier date, likely 26 July 2022 being a Tuesday (the day of the week Dr Shaw usually attended the RACF for medical reviews) a week prior to the 2 August 2022 consultation (noting the request to review in a week) and being at a time close to when Adelina started to complain of knee 28 RACF progress notes 11.19am and 2.04pm 2 August 2022.

29 RACF progress notes 11.19pm 2 August 2022.

30 THS Medical Records: Letter referral Dr Shaw to “doctor” dated 2 August 2022.

pain. Whilst speculative if this timeline is correct, it reflects symptoms had commenced in the right leg by 26 July 2022.

Following Dr Shaw’s review of Adelina on 2 August 2022, AT attended the RACF and transferred Adelina to the RHH.

At the RHH Adelina was diagnosed with an acute limb ischemia. She was admitted under the vascular surgical team. The right lower limb was assessed as a category III on the Rutherford Classification Scale (a scale used to assess the prognosis for acute limb ischemia) and was accordingly considered “unsalvageable”.31 The only surgical option available for Adelina was a right above knee amputation. This was considered to be at the cost of a significant decrease in the quality of her life, posed a high risk of mortality and had a long-term prognosis of less than one year.32 In consultation with her family the decision was made to not proceed with operative intervention and to provide palliation. This decision was considered by the vascular surgical team at the RHH to be reasonable.33 Adelina died in the presence of John and her granddaughter in the early morning of 3 August 2022.

The cause of Adelina’s death In considering the cause of Adelina’s death, I have been assisted by the State Forensic Pathologist Dr Andrew Reid. In his Short Final Report of Death to the Coroner Dr Reid identifies the cause of Adelina’s death as acute right lower limb ischemia. Dr Reid notes Adelina’s comorbidities, specifically, atrial fibrillation, hypertension, chronic kidney disease and congestive cardiac failure (pacemaker dependent) and considers that whilst an embolectomy might have saved Adelina’s leg she may have died in any event from these comorbidities.

Was there a failure to escalate Adelina’s care?

Dr Bell (MD FRACP FCICM), Medical Advisor to the Coroner, has considered the relevant records of the RACF and RHH regarding Adelina’s care.34 In his opinion the RACF failed to appropriately care for Adelina regarding her right leg symptoms. He notes that considering her ongoing and apparently escalating pain, unrelieved by simple analgesia, the RACF therapeutic approach ought to have changed.35 I accept Dr Bell’s opinion. Whilst Dr Bell 31 RHH Medical Records.

32 RHH Medical Records.

33 RHH Medical Records.

34 Report Dr Bell dated 17 October 2023.

35 Report Dr Bell dated 17 October 2023, page 2.

notes that this failure has occurred in a context where obtaining rapid medical assessment, especially general practitioner review in an RACF can be difficult and it is “not actually simple”36 to access emergency department assessment given those departments are often “overfull”.37 I find there was insufficient effort directed toward obtaining urgent medical review by either a general practitioner or at an emergency department of a hospital by the RACF prior to 2 August 2022.

I have also been assisted by Mr Egan, nursing advisor to the coroner, who makes similar criticism of the RACF’s response to Adelina’s condition.38 He identifies that the failure of the RACF to have escalated Adelina’s care and responded to her and her family’s concerns regarding her right leg symptoms as concerning.39 He notes a six to seven day period of ongoing and worsening leg pain, lack of staff urgency in Adelina’s care, the minimal effect of paracetamol and absence of clinical reviews. Mr Egan describes the visualisation of the leg or the assessment of sensation and circulation as “basic health assessment[s] able to undertaken by any registered nurse, enrolled nurse or allied health professional”.40 Given the lack of such assessments recorded of the leg Mr Egan observes that it is impossible to conclude whether the leg had a vascular compromise before the acute ischemic event on 2 August 2022.41 He notes that Adelina’s care plan at the RACF required the daily fitting of compression stockings on Adelina in the morning and removal of the stockings in the evening.42 This would have provided two opportunities daily for Adelina’s right leg to have been visualised by care staff. No mention is made in the care records of any detection of colour or temperature changes in the right leg. This may reflect that the changes were not present or discernible or if present and detectable care staff were not adequately trained to appreciate their significance and record their existence.

I find that by at least 28 July 2022 Adelina was experiencing right leg symptoms including pain that was significant enough for her to be in frequent telephone contact with her children seeking their assistance to escalate her care.

The provision of paracetamol by the RACF failed to resolve or significantly moderate Adelina’s symptoms from this time. During this period Adelina and her family sought her care be escalated by general practitioner review or hospital transfer. Adelina’s condition continued to worsen. These matters ought to have caused the RACF through their nursing staff to have shifted or escalated their therapeutic approach at a time earlier than they did.

36 Report Dr Bell dated 17 October 2023, page 2.

37 Report Dr Bell dated 17 October 2023, page 2.

38 Report Mr Egan dated 10 October 2023.

39 Report Mr Egan dated 10 October 2023 page 1.

40 Report Mr Egan dated 10 October 2023 page 2.

41 Report Mr Egan dated 10 October 2023 page 2.

42 RACF Other Complex Health Care Directive dated 19 May 2022.

On 31 July 2022, when the RACF did seek medical review as soon as possible through AAC no assistance was provided beyond the standard consultation scheduled for 2 August 2022 and no action taken by RACF to seek urgent medical assistance elsewhere including by requesting AT attendance.

Adelina’s complaints of pain and coldness in her right leg, her requests for hospital transfer, the frequent calls made by her to her children for assistance and their requests for general practitioner review are matters which, in addition to the failure of paracetamol to moderate the pain, ought to have resulted in action from the RACF to escalate their care. At this time the RACF were in lockdown due to COVID-19 as such Adelina’s children were not able to enter the facility and see her and were entirely reliant on the RACF to appropriately assess and respond to her condition.

This failure of the staff of the RACF to have appropriately escalated the care of Adelina may have been contributed to by the lack of a procedure for the undertaking and recording of neurovascular changes to the leg and reflected a lack of understanding of the RACF escalation policy.

Given Adelina’s stage of life and medical comorbidities the outcome may not have been any different had the ischemia been detected earlier.43 An early and accurate diagnosis of an ischemic event may have been frustrated by the possible red herrings of the 20 and 30 July 2022 falls as possibly causative of her symptoms had she presented to the emergency department of the RHH at an earlier time and shortly after the commencement of her symptoms.44 Adelina’s cognitive decline would also have made the obtaining of an accurate history difficult.45 Comments and Recommendations In these findings I have criticised the failure of the RACF to appropriately escalate the care of Adelina in respect of her right leg symptoms. The RACF have been provided with the reports of Dr Bell and Mr Egan which I have relied upon and been given the opportunity to comment. A response was received from the RACF under cover of letter 16 November

2023. In that response the RACF acknowledge that their nursing staff failed to escalate the request for urgent locum appointment through AAC by utilising the Hello Home Doctor service or AT. They further acknowledge that there are opportunities for improving their monitoring and assessment of neurovascular changes which were absent in Adelina’s case.

The RACF advise that in light of the omissions highlighted by Adelina’s case they have 43 Report Dr Bell dated 17 October 2023; Report Mr Egan dated 10 October 2023.

44 Hospital Report of Death to the Coroner dated 05 August 2022.

45 Hospital Report of Death to the Coroner dated 05 August 2022.

implemented measures to improve the quality of their care to residents of their facility including by:

• Providing education for nursing staff on recognising and managing deteriorating patients on 17 August 2022;

• Commenced a program of supporting staff with weekly clinical updates in 2022;

• Monitor PainChek usage monthly;

• Increased numbers of Registered Nurse Level 2 staff in addition to the around the clock registered nurse on site. The level 2 position covers morning, and afternoon shifts seven days a week to assist guide the clinical care of residents;

• Support level 2 learning through the University of Tasmania;

• Introduction of an extended care assistant team leader position to provide leadership and support on complex care to the care staff;

• Introduced a CN Quality and Compliance in the south to provide support and education for continuous improvement; and

• Provided further education and support for nursing staff on recognising and responding to deterioration as part of the annual education plan.46 In light of the RACF’s recognition of the deficits in their care of Adelina and the approach taken by them to improve their processes, training and expertise as a result, I do not make any recommendations pursuant to Section 28 of the Coroners Act 1995.

I convey my sincere condolences to the family and loved ones of Ms Zito.

Dated: 8 April 2025 at Hobart, in the State of Tasmania.

Leigh Mackey Coroner 46 Letter OneCare to the Magistrates Court of Tasmania 16 November 2023.