A resident of Ascott Gardens for three years, Hazel Neal died on December 21, 2020 at around 2.50pm due to septic shock, acute renal failure and a UTI.

A report produced by the Aged Care Quality and Safety Commission and seen by the Central Western Daily said "the assessment and management of Mrs Neal's clinical deterioration in the weeks prior to her death was inadequate".

One of the concerns raised to the Clinical Unit was that Mrs Neal was overprescribed medications in the last few months of her time at the service, to the point that it "constituted chemical restraint".

"The Clinical Unit considers that administration of psychotropic medication to Mrs Neal at times did constitute the use of chemical restraint because, despite legislation stating that psychotropic medicines are to be used as a last resort, between December 18 and 21, 2020, there was no evidence within the progress notes that any non-pharmacological interventions were trialled prior to administering increasing doses of olanzapine, psychotropic medicine to manage Mrs Neal's agitation," the report read.

"Non-pharmacological strategies developed to manage Mrs Neal's behaviours of concern were generic, non-personalised and inadequate as they give no consideration to assessing for unmet needs, such as pain, continence, hunger, thirst, boredom, etc., which may be contributing to her changed behaviours."

The report added that "there was no evidence that the service" - which is run by non-for-profit United Protestants Association - "arranged for Mrs Neal to undergo review with a behaviour management specialist for additional non-pharmacological interventions to manage Mrs Neal's changed behaviours".

Provisions within the Aged Care Act 1997 state that psychotropic medicines prescribed for managing behavioural responses are only to be used as a last resort after all non-pharmacological behaviour management interventions have been trialled and failed.

Mrs Neal's daughter, Valerie Fox, said she "felt disgusted" when she read the report.

"I knew that there would be non-compliant findings," she told the Central Western Daily.

"My mother meant the world to me. We were very close. I cannot forget the way she was treated.

"I see the vision of her crawling and begging me to take her home every day."

The Clinical Unit also noted that the administration and management of Mrs Neal's medicines was not adequate because "on at least one occasion in June 2020, Mrs Neal was left with Panadol Osteo tablets in her mouth overnight as staff had not checked that she had swallowed these tablets at the time of administration".

When asked about the report, a statement from Ascott Gardens said it could not comment on specifics due to "privacy" but acknowledged that during a performance report on December 10, 2021, the ACQSC found one area of non-compliance in relation to personal care and clinical care.

"Ascott Gardens was found non-compliant on one of the seven areas within Standard 3 of the 44 standards in the Commission's ratings," the statement read.

"Upon receipt of the report, we immediately conducted an internal review of our practices in relation to this area which included ensuring documentation of our use of non-pharmacological interventions and implemented a continuous improvement program in response.

"ACQSC undertook a four-day assessment at Ascott Gardens recently (April 5, 2022 to April 8, 2022) and we have been provided with a copy of its draft report which found Ascott Gardens to be fully compliant in all aspects of clinical care.

"Our staff work hard to deliver the best quality care for our residents, and we have continued to do this through the COVID-19 pandemic and the challenges it has brought and we remain very grateful and proud of their efforts."

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