Unexpected death | Aged Care Quality and Safety Commission

What is unexpected death?

Unexpected death is where the death of a consumer is:

the result of care or services provided to a consumer
the result of a failure to provide care or services
where reasonable steps were not taken to prevent the death.

You must notify the Commission of any incident of unexpected death that:

happens in your service
somebody has alleged happened at your service
you suspect may have happened at your service.

What is unexpected death?

Unexpected death is where due to care or services provided by the provider or a failure by the provider to provide care and services.

For providers of home services, there is limited control and visibility over a consumer’s day-to-day living circumstances and your service may not become aware of a consumer dying until some time later. You may never be aware of the circumstances of their death and the consumer’s family is not obligated to share this information with you.

Home services are required to notify the Commission of any death where the provider, including any worker engaged by the provider:

made a mistake resulting in death
did not deliver care and services in line with a consumer’s assessed care needs, resulting in death
provided care and services that were poorly managed or not in line with best practice, resulting in death.

Unexpected death includes deaths where you as the provider or your workers and professionals working at your service:

did not take appropriate steps to prevent or mitigate an incident
did not appropriately assess or treat a consumer following an incident, for example where a pressure wound is not treated and becomes infected resulting in the consumer’s death
were (or reasonably should have been) aware of a consumer’s condition and did not take steps to treat the consumer
made clinical mistakes resulting in death
delayed medical assessment or treatment resulting in a consumer’s death. For example, where a consumer falls and is not assessed immediately afterwards and later dies because of injuries sustained from the fall
did not deliver care and services in line with a consumer’s assessed care needs resulting in death
delivered care and services that were poorly managed that resulted in death
delivered care and services that were not in line with best practice that resulted in death
are involved in moving or shifting a consumer who falls, and the injuries sustained in the fall resulted in the consumer’s death
provide poor quality clinical care to a consumer resulting in their death. For example, where a pressure injury or wound is untreated or not regularly tended to and becomes infected resulting in the consumer’s death.

Unexpected death includes deaths where you as the provider or your workers and professionals working at your service:

were involved in moving or shifting a consumer who falls, and the injuries sustained in the fall resulted in the consumer’s death
provided equipment or supports that malfunctioned and caused the consumer’s death, such as where grab rails have been poorly installed and break, causing the consumer to fall and die
provided poor quality clinical care to a consumer resulting in their death. For example, if a provider is responsible for treating a consumer’s wound, and a pressure injury or wound is not appropriately treated and becomes infected, resulting in the consumer’s death
repeatedly failed to attend or did not provide regular care and services that a consumer was reliant on and the consumer died as a result of this lack of service or neglect.

Unexpected death does not include:

a consumer dying of an illness or disease that was appropriately assessed, monitored and managed.
a consumer dying of an illness for which they were receiving palliative care and appropriate end of life medications
a consumer dying of unrelated illness after being involved in an incident
deaths resulting from outbreaks of disease.

Unexpected death does not include:

a consumer dying after an accident not connected to care and services
a consumer who is involved in an incident and later dies of an unrelated illness
a death resulting from an outbreak of disease, unconnected to the provision of care and services
a consumer dying of an illness for which they were receiving palliative care and appropriate end of life medications
a consumer dying as a result of an ongoing illness, disease or condition that was appropriately assessed, monitored and managed by the provider who is responsible for providing clinical or palliative care.

An unexpected death may happen immediately after the mistake or failure, or at a later time.

If you suspect a death may have been related to a mistake or failure, you should report it to the Commission as an unexpected death.

Work tool

The SIRS Decision Support Tool can help you explore what kinds of deaths are reportable incidents.

Reporting unexpected death

All unexpected deaths are Priority 1 reportable incidents and must be recorded in your IMS and reported to the Commission within 24 hours of your service becoming aware.

A quality incident notification requires more than simply transcribing the details from progress notes about the incident or copying text from your incident management system. It is important that the person making the notification is familiar with:

what happened
when the incident happened
where the incident happened
who was involved including the affected consumer, workers involved with the incident, and other affected people
what actions were taken after the incident
what caused the incident (if known)
what changes will be made as a result of the incident (if known).

If you become aware of further information after submitting your initial notification you should update the Commission.

When you provide clear and comprehensive information early on, it is less likely that the Commission will need to:

ask for further details
require you to conduct an investigation
directly investigate the matter itself.

Reporting unexpected death

All unexpected deaths are Priority 1 reportable incidents and must be recorded in your IMS and reported to the Commission within 24 hours of your service becoming aware.

The reporting responsibility only exists where the service is aware of the death and where the service has reasonable grounds to believe the unexpected death has occurred, or is alleged or suspected to have occurred, as a result of the service’s action or inaction.

A quality incident notification requires more than simply transcribing the details from progress notes about the incident or copying text from your incident management system. It is important that the person making the notification is familiar with:

what happened
when the incident happened
where the incident happened
who was involved including the affected consumer, workers involved with the incident, and other affected people
what actions were taken after the incident
what caused the incident (if known)
what changes will be made as a result of the incident (if known).

If you become aware of further information after submitting your initial notification you should update the Commission.

When you provide clear and comprehensive information early on, it is less likely that the Commission will need to:

ask for further details
require you to conduct an investigation
directly investigate the matter itself.

All unexpected deaths are Priority 1 reportable incidents and must be reported to the Commission within 24 hours of your service becoming aware.

Tip

You do not need to notify the Commission of deaths where the cause of death is unclear.

You should only report deaths where there are reasonable grounds to consider it may have occurred as a result of the provider’s action or inaction.

Other reporting obligations

You may also be required to report an unexpected death to other parties such as the coroner or police, depending on the rules in place in your state or territory. The coroner’s role is to determine the date, place, circumstances and cause of the death.

You may not have all the required information when you first notify the Commission of an unexpected death, pending investigations into the death from other parties. You are expected to notify the Commission of any new information as it becomes available, following the initial report within 24 hours of the incident. The Commission will negotiate ongoing reporting timeframes with you.

Tip

It is easier to make a good quality notification to the Commission if you have the information you need at hand.

Educating workers to report incidents correctly within your IMS will make it easier to notify the Commission when a reportable incident happens.

Work tools

The fact sheet, Reportable incidents: unexpected death, provides more detailed guidance for reporting of incidents in a residential service relating to this incident type.

The example Unexpected death notification shows the level of detail the Commission expects when receiving a notification about this incident type.

You can use the Practical tips guide to ensure your notification contains all of the required information.

Work tools

The fact sheet, Reportable incidents: unexpected death, provides more detailed guidance for reporting of incidents in a home or community setting relating to this type of reportable incident.

Contact us

If you have a question about the SIRS, you can call us on 1800 081 549.

This phone line is open 9 am to 5 pm (AEST) Monday to Friday and 8 am to 6 pm (AEST) Saturday to Sunday.

You can also email us at sirs@agedcarequality.gov.au.

Facilitated Workshops

The Commission provides facilitated workshops to sector participants. All current workshops are available on the Commission’s Workshop page.

Online Learning

The Commission’s Aged Care Learning Information Solution, Alis provides free online education for employees of Commonwealth-funded aged care providers, including a module covering Unexpected death.

You can access Alis at learning.agedcarequality.gov.au.

Disclaimer

The information contained on this page is intended to provide you with general guidance; however, it is your responsibility to be aware of your legislative requirements.