Aged Care Register of Coroners’ Recommendations

The department extends its condolences to the family, friends, and loved ones of those whose deaths are the subject of coroner’s recommendations appearing in this register.

Coronial inquests serve a vital public purpose: learning from a tragedy to protect the living. Through careful investigation, coroners identify systemic risks and recommend specific changes to government bodies. These recommendations help to inform changes to laws and public safety procedures, helping to ensure that tragic losses lead to lasting, life-saving change.

Under Section 341 of the Aged Care Act 2024, the System Governor is required to maintain a publicly available register of reports sent by state and territory coroners to the Department of Health, Disability and Ageing about the death of an individual accessing funded aged care services where those reports include a recommendation to the department.

Subject to privacy considerations, the register contains:

the circumstances of the death of the individual
the recommendations made to the department, and
a summary of any actions taken by the department in response to those recommendations.

The register will be published on this page and progressively updated as soon as possible after we receive any relevant coroners’ recommendations.

A report to the Inspector-General of Aged Care will be provided each year, covering:

the recommendations made to the department
a summary of actions taken by the department in response to these recommendations, and
an evaluation of the effectiveness of those actions.

Register of aged care coroners’ recommendations

Circumstance of reported death	Recommendations to the department	Summary of any actions taken by the department in response to those recommendations
Date of Death: October 2020 Jurisdiction: South Australia Acute or chronic renal failure caused by severe dehydration, on a background of Lewy body dementia, Parkinson’s disease, and congestive cardiac failure.	That consideration be given to amending the final Strengthened Aged Care Quality Standards to include the following requirements (potentially within standard 5.5.5): The provider implements processes to maintain an older person’s hydration by: Measuring the daily fluid intake of residents who are clinically dehydrated Measuring the daily fluid intake of residents assessed as being at risk of dehydration, including all residents living with dementia and residents being administered diuretic medication/s Recognising inadequate fluid intake Responding to inadequate fluid intake	The department notes the recommendations made by the SA Coroner concluding their inquiry into this matter. Hydration risks are already comprehensively covered through existing legislated outcomes in Strengthened Quality Standard 6 (Food and Nutrition) and Strengthened Quality Standard 5 (Clinical Care). The specific recommendations for hydration processes have been noted for further consideration in the next 5‑year review of the Quality Standards. In the interim, the Department will work with the Aged Care Quality and Safety Commission to incorporate the recommendations into non‑mandatory guidance materials, rather than the standards themselves.

Circumstance of reported death

Recommendations to the department

Summary of any actions taken by the department in response to those recommendations

Date of Death: October 2020

Jurisdiction: South Australia

Acute or chronic renal failure caused by severe dehydration, on a background of Lewy body dementia, Parkinson’s disease, and congestive cardiac failure.

That consideration be given to amending the final Strengthened Aged Care Quality Standards to include the following requirements (potentially within standard 5.5.5):

The provider implements processes to maintain an older person’s hydration by:

Measuring the daily fluid intake of residents who are clinically dehydrated
Measuring the daily fluid intake of residents assessed as being at risk of dehydration, including all residents living with dementia and residents being administered diuretic medication/s
Recognising inadequate fluid intake
Responding to inadequate fluid intake

The department notes the recommendations made by the SA Coroner concluding their inquiry into this matter.

Hydration risks are already comprehensively covered through existing legislated outcomes in Strengthened Quality Standard 6 (Food and Nutrition) and Strengthened Quality Standard 5 (Clinical Care).

The specific recommendations for hydration processes have been noted for further consideration in the next 5‑year review of the Quality Standards.

In the interim, the Department will work with the Aged Care Quality and Safety Commission to incorporate the recommendations into non‑mandatory guidance materials, rather than the standards themselves.

Date last updated:

10 September 2026

Tags:

Aged care