Wall of Shame #4 – Tied to a Toilet and left to Die!

Here’s another horrible incident that has happened in a nursing home facility. It’s the negative outcomes like this that continue to plague our industry and give the public such a poor perception of what a nursing home is really like.

From the Herald Sun:

Widow Gwendoline Gleeson was put in a restraining belt and placed on a toilet at Barrabill House nursing home in Seymour in August last year and forgotten by staff who later found her dead.

There was no physical reason why the nylon restraining belt was used on Mrs Gleeson other than it being used to free up staff who would otherwise have to supervise her, material before the Coroner’s Court states.

Mrs Gleeson, who had previous heart problems, was diabetic and had early stage dementia, died of a heart attack – of natural causes according to doctors.

Son James Gleeson, 69, said he found out only today that his mother was tied to the toilet and said he previously assumed she had only been overlooked for a matter of minutes – not two hours.

“I don’t want this to happen again to anybody … mum has passed away and I find out 12 months later what has happened and she was left tied to a toilet,” Mr Gleeson said.

“I’m pretty crook about it, I didn’t know a thing about it,” he said, adding a doctor had told the family it wasn’t believed the stress of being left alone in the toilet had killed his mother.

But Mr Gleeson said he was angry he had been kept in the dark about the circumstances, including not being told restraining belts were used to tie his mother to the toilet while staff went off to other duties.

“I was under the impression it was for 10 minutes, I thought it was 10 minutes, not two hours,” Mr Gleeson said.

He said his mother, who was widowed about 15 years ago, had been at Barrabill nursing home for about 10 years and he had seen staff take her to the toilet numerous times in the past.

He said they would normally leave her in the cubicle alone and come back a few minutes later when his mother rang a bell.

Mr Gleeson said his mother was owed a duty of care and proper supervision and should never have been tied to a toilet.

Coroner John Olle said today the circumstances of Mrs Gleeson’s death were particularly distressing and he sent a public message that such restraint practices should not be tolerated and that nursing home residents should be supervised at all times when necessary.

“If it’s happening here (at Barrabill) it might have happened elsewhere, it might be happening elsewhere,” Coroner Olle said.

In fact, court material showed at least two other residents at Barrabill, with the knowledge of relatives, were being subjected to the toilet restraints at the time of Mrs Gleeson’s death.

But Mrs Gleeson’s care plan contained no family authorisation for the restraints and stipulated she be supervised during toileting.

After being seen by a doctor on the morning of her death, Mrs Gleeson was placed on the toilet about 2.45pm by staff from the morning shift.

A restraining belt was attached to hand bars beside the toilet and around her waist.

A staff shift change occurred at 3pm and the afternoon shift, who were apparently unaware of Mrs Gleeson’s whereabouts, did not discover her until 4.40pm.

Coroner Olle said Seymour Health, which runs Barrabill, acted swiftly after the death in removing all restraints from toilets after a complaint was made to the Department of Health and Ageing.

A number of staff were disciplined and faced further training as a result of the incident.

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