Reforming aged care to reduce preventable deaths

Professor Ibrahim, Head of the Health Law and Ageing Research Unit at Monash University prepared his report on harm prevention based on inquiry related deaths of the aged in residential care.


Professor Ibrahim explained the report is a culmination of an in-depth analysis that took three years into injury-related deaths of older people living in accredited Australian Residential Aged Care Services, often called nursing homes.


This comprehensive report titled “Recommendations for prevention of injury-related deaths in residential aged care services” was presented to the Senate Community Affairs Reference Committee Inquiry on the 22 November 2017 in Adelaide which is examining the effectiveness of the Aged Care Quality Assessment and accreditation framework for protecting residents from abuse and poor practices, and ensuring proper clinical and medical care standards are maintained and practised. The Inquiry was established in response to the shocking events at Oakden in South Australia.


The Monash University report provides recommendations on preventing harm in seven areas:

  • choking
  • medication
  • physical restraint
  • resident-to-resident aggression (RRA)
  • respite
  • suicide
  • unexplained absence.


The research group applied three methods to develop this evidence including reviewing existing international literature reviews, examining deaths among nursing home residents reported to Australian coroners; and drawing on the knowledge and experience of experts and key stakeholders.


From this 104 recommendations were generated to reduce the risk of deaths in the future for consideration by government, RACS providers and other agencies and professionals with a mandate or interest in the health and safety of nursing home residents.


In addition the Monash research team proposed an additional eight recommendations that apply broadly to the whole of the aged care sector. These eight recommendations arose from the research team’s key reflections and observations are that older persons in RACSs suffer preventable harm and that the workforces in the community, law, health and aged care sector are ill equipped to address the issue.


Systemic factors and not individuals are the underlying cause compounded by knowledge gaps to inform evidence-based policy and practice in aged care. The lack of academic discourse and absence of leadership for improving quality of care in RACS means the status quo is not being challenged.


Professor Ibrahim said, “Australia requires a Program for Improving Quality of Care and Safety for Residents and Staff. This program would promote organisational leadership, a respectful, transparent, resident-centred culture and continuous learning, the use of a standard nationally gathered empirical data; together these elements will provide residents an opportunity to thrive and enjoy their lives.


“We hope this report leads to a collaborative effort where every RACS in Australia is considered to be a high performing organisation with systems in place to deliver and evaluate their service.”


The full report is available at:


The 22 November 2017 ABC TV 7:30 Report on preventable deaths is available at:


13 December 2017.