Aged care in crisis

“While I was at break, there has been a murder. The resident has murdered another resident.”

Kathryn Nobes, an aged-care worker with an unnamed employer in Sydney, is giving evidence before the royal commission into the aged-care industry. A quiet, upright middle-aged woman in a floral-print blouse, Nobes reads her prepared statement carefully into the record. She takes her time and keeps her voice even.

She is quoting a colleague who found an aged-care resident dead in their room, beaten to death by another resident, an elderly man with advanced dementia. Shortly before the body was discovered, Nobes encountered the perpetrator “holding a walking stick in his right hand, like it was a club”. He had blood on his hands, clothes and face. She thought he had fallen and suffered a nosebleed. After the death, Nobes was diagnosed with post-traumatic stress disorder.

She alleges that “the management of the facility made it difficult for me to talk to the police” and expresses concern “about the safety and wellbeing of the care workers”.

She tells the commission of being attacked by another resident with dementia, who covered his fists with his own excrement and punched her in the breasts, arms and back. She recalls care workers enduring racial abuse and inappropriate sexual behaviour, and residents urinating and defecating in public areas. One nurse told Nobes a resident had urinated onto her computer keyboard.

Nobes paints a picture of an unsupported, exhausted workforce, unable to provide decent care with the scant resources they are given. There were often no cleaning products, continence aids or wipes to clean residents’ bodies, forcing workers to use wet paper towels. Nobes would sometimes be the only aged-care worker in charge of a floor of 18 male residents, some of whom had a history of violence and sexual disinhibition. When she complained about being headbutted, punched, kicked and threatened, her superior shrugged and said, “That’s dementia.”

The royal commission has taken over the seventh floor of the Lionel Bowen Building in Sydney’s legal precinct. The premises is home to the Family Court and has heard many stories of abuse, cruelty and neglect. Commission witnesses are called either to share their experiences or to explain their culpability. As they wait to be called, those whom the aged-care industry has failed sit metres away from the representatives of the companies that failed them.

Counsel Assisting Paul Bolster, who leads the questioning, changes his demeanour dramatically depending on who is in the witness box. With the families of aged-care residents and care workers who have spoken out about malpractice, he is solicitous, his questioning helpful and shot through with gentle humour. With people who presided over substandard care or negligence, he is cutting, sardonic, at times bordering on angry.

Two sisters, giving evidence on condition that their names not be published, recount the experiences of their elderly mother who lives with dementia, and is a resident at Anglicare’s Brian King Gardens in the north-western suburb of Castle Hill. She is referred to in the commission transcript as Mrs CO.

Mrs CO’s toenails were allowed to grow for months without being trimmed, eventually cutting into the flesh of her toes. Her partial denture, which was meant to be removed and cleaned every night, was left in her mouth for weeks, causing several of her remaining teeth to rot. Her daughters once found her trapped between a brick wall and some wrought-iron fencing at the perimeter of the facility. On at least one occasion, she was accidentallygiven someone else’s medication.

Cheryl Lee, a speech pathologist who examined Mrs CO, tells the commission the elderly woman was regularly given hard and crunchy food that she was unable to swallow. Due to her dementia, Mrs CO would often try to eat quickly, fill her cheeks with food she could not chew, become distressed and let the food spill out of her mouth.

Mrs CO was also administered a powerful anti-depressant, her family’s consent only obtained after the fact. Without conducting a formal assessment or taking notes, consulting GP Dr Margaret Ginger diagnosed Mrs CO with depression and prescribed an unusually high dosage of mirtazapine, an antidepressant that the Australian Medicines Handbook warns seems “ineffective in people with dementia and depression”.

“I really have no explanation why I did that,” Ginger admits in the witness box.

Mirtazapine had a powerful soporific effect on Mrs CO. When her daughter and granddaughters came to see her on her birthday, they could not wake her.

Richard Farmilo, the resident manager of Brian King Gardens, admits that Anglicare does not have a standing policy relating to patient consent in treatment, although that stance is under review. This constitutes “substandard care”, he says, but fails to explain why an apology to Mrs CO’s family did not mention many of the ways in which she was poorly treated.

“I don’t think we have a clear-cut policy around what the rules are, around documenting,” Farmilo tells the commission.

Questioning Farmilo, Bolster brings up the term “ACFI gaming”, which describes a practice among aged-care providers of misrepresenting residents’ care needs to obtain more money under the federal government’s Aged Care Funding Instrument. Under ACFI guidelines, residents in pain are worth more to aged-care facilities, which can request up to $7000 in additional government funding for each resident requiring “complex healthcare”, including more significant levels of pain management.

Despite Mrs CO’s patient notes describing her level of pain from arthritis as negligible, Farmilo pushed for her to be classed as needing a high level of pain-management care, and therefore render Brian King Gardens eligible for more ACFI funding.

“What needs to change to make Mrs CO a [high-level patient] … or is this not possible?” Farmilo asked his ACFI coordinator in an email.

Farmilo denies Bolster’s assertion that the desire for more ACFI funding was “driving the issue” rather than Mrs CO’s care.

The hearings continue.

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