Ruth Harriet Carter, 1923-2018

AGED CARE SCANDAL: Death probed by health watchdog

28th July 2018 5:00 AM
UPDATED 29th July 8:36 AM
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A DARLING Downs nursing home is at the centre of a scandal surrounding the quality of care given to at least four of its residents.

A nine-month long investigation by The Chronicle can reveal multiple cases involving the Millmerran Centenary Retirement Village have been probed by health authorities.

The cases include the death of 94-year-old grandmother Ruth Carter (pictured above), which remains under investigation.

This week, an Aged Care Complaints Commissioner investigation into the case of a 64-year-old resident who nearly died earlier this year found the facility "failed to adequately document" the man's clinical notes, or "escalate his condition to a doctor when he was unwell".

The ACCC said as a result of the complaint, the service had implemented "a range of quality improvements".

In this exclusive investigation, family members are speaking out in the hope that increased scrutiny will improve conditions at the community-owned-and-run facility.

The Chronicle has confirmed that the death of Ruth Carter, 94, who suffered from two severely infected bedsores and a resulting sepsis infection is being investigated by Queensland's Office of the Health Ombudsman.

Mrs Carter was a resident at the Millmerran Centenary Retirement Village, also known as Yallambee Aged Care, until the time of her death in February this year.

Millmerran Centenary Retirement Village, also known as Yallambee Aged Care (34-40 Margaret St, Millmerran). Saturday, 14th Jul, 2018.
Millmerran Centenary Retirement Village, also known as Yallambee Aged Care (34-40 Margaret St, Millmerran). Saturday, 14th Jul, 2018. Nev Madsen

Her story is not the only one to emerge from the facility, which was without a full-time visiting medical service for 13 months between February 2017 and March 2018.

The Chronicle can reveal a family is considering legal action after their 71-year-old grandmother died of a heart attack after contracting urosepsis, also in February this year.

In another case, a 64-year-old grandfather contracted sepsis and pneumonia and nearly died in Toowoomba Hospital after a brief, three-month stay at the facility between October 2017 and January 2018.

His case has been finalised by the Aged Care Complaints Commissioner and he has been moved into a different nursing home.

In another instance, a Millmerran woman said she had to push her sick mother, in a wheelchair, through the pouring rain to get to a doctor's appointment after reportedly being told the facility's bus was "only used for outings".

After reaching the doctor's surgery, the elderly woman was rushed to hospital in an ambulance, where she remained for 10 days due to her illness.

The woman has since been moved to another nursing home.

Millmerran: Health facilities in Millmerran, Queensland.
Millmerran: Health facilities in Millmerran, Queensland.


Aged 94, Ruth Carter was frail, wheelchair-bound, and suffering from dementia.

Her death is now under investigation, following a complaint to the Office of the Health Ombudsman from her doctor - Millmerran's Dr Andrew Reedy.

The Chronicle has obtained a copy of that complaint, which alleges Yallambee Aged Care failed to inform Dr Reedy or Mrs Carter's family of her deteriorating condition, and that her treatment involved a lack of basic care.

The complaint states that on January 25, Dr Reedy received a fax from Yallambee, stating that Mrs Carter "had some pressure areas, and appropriate cares were being implemented".

Dr Reedy wrote he requested by telephone Mrs Carter be brought in for medical review so the reported pressure areas could be examined.

QRME host breakfast to launch their reconciliation action plan as part of National Reconciliation Week. Andrew Reedy chairman QMRE board.Photo: Bev Lacey / The Chronicle
FILE PHOTO: Millmerran's Dr Andrew Reedy Bev Lacey

"Request declined by nursing staff, as stated insufficient staff to escort patient on that day, and family would be notified of patient status and they would decide if review was needed," Dr Reedy wrote in his complaint.

On the afternoon of Monday, February 5 - 11 days later - Dr Reedy received by fax, a request to increase Mrs Carter's dosage of painkillers as she was "in discomfort when undergoing manipulation in bed to attend to basic cares".

One of Mrs Carter's daughters arrived at Dr Reedy's practice, the Millmerran Medical Centre, with the medical chart to note down the increased painkiller dosage, and made no mention of any concerns about pressure sores, he wrote.

The next morning, Dr Reedy received another fax request "for further increased analgesia from nursing staff at Yallambee, as reported pain levels not controlled on previously increased medication".

"I contacted Yallambee facility and requested review of patient at medical centre, again declined as stated patient to (sic) frail to travel to medical centre, daughters were present with mother, and were happy with her current status," Dr Reedy wrote.


According to Dr Reedy's complaint, he immediately contacted Mrs Carter's daughters and "informed them that I had serious concerns regarding their mother's status, that two requests for increased analgesia within 24 hours was an alarm bell, and there was something not right with the clinical picture being portrayed by nursing home staff".

Mrs Carter was transported by ambulance to the Millmerran Multi-Purpose Health Service, also known as the Millmerran Hospital.

"I was contacted immediately by hospital nursing staff when pressure injuries were detected. A very detailed description of injuries, the poorly applied wound care / packing that had been attempted and the rancid state and infection / cellulitis of the wound was relayed to me by hospital staff, and documented in the medical file," Dr Reedy wrote.

"Neither of Mrs Carter's two daughters were aware of the extent of the injuries. They were both shocked and as horrified as the nursing staff at the hospital were when they discovered the injuries.

"The ulcers were extensive and the vertebral column was visible in the base of the wounds. Photographs were taken that show a light shined into one ulcer, transmitted light out through several other deficits in the skin. The wound was extensive."



Bed sores, Millmerran.
A photo of Ruth Carter’s “extensive” bed sores on her lower back and at the base of her spine. Contributed

Mrs Carter's family agreed she would have wanted to begin palliative measures, which started on the morning of February 7. She died in her sleep later that day.

The Chronicle contacted Yallambee with details of Dr Reedy's complaint.

Their lawyer issued a statement saying: "We advise that on February 27, the MCRV responded - in detail - and refuted the allegations made by Dr Reedy to the OHO concerning the care received by the late Mrs Ruth Carter".

"It is not appropriate for any person to publicly comment any further on that continuing investigation."