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Coffee burn led to $281K undertaking

A resident in an aged care home suffered serious burns from hot coffee.
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Coffee burn led to $281K undertaking

Coffee burn led to $281K undertaking

7 August 2020

By Gaby Grammeno

A catering business has entered into an enforceable undertaking that will cost it more than $281,000, after a resident in an aged care home suffered serious burns from hot coffee.


The incident

The company with liability for the incident provides catering services and hospitality to the aged care sector as well as other business, industry and educational facilities. The incident occurred in a residential aged care home in Victoria, for which the company provided a chef, catering assistants and food and beverages for residents.

During the serving of afternoon tea, black coffee was provided for an elderly resident who was unable to communicate and mostly immobile, with limited upper body strength. The hot coffee was put on her over-bed table, and a short time later an employee noticed that the woman was thrashing about, as the coffee had spilled onto her leg.

The resident sustained serious burns to her upper thigh. She died two weeks later.

The catering business was charged with failing to ensure that persons other than employees were not exposed to health and safety risks arising from the caterer’s work activities. In particular, WorkSafe Victoria alleged that the company had failed to ensure its employees had sufficient information to perform their tasks correctly, and/or that they had received adequate site induction to familiarise them with the location of the emergency/call buttons they were to use in the event of an emergency.


The enforceable undertaking

As an alternative to prosecution, the company offered an undertaking to WorkSafe, to be carried out over a two-year period.

The company’s commitments as part of the undertaking include the employment of a person to make remedial changes to the organisation's management system and introduce the Commonwealth Aged Care Quality and Safety Commission's Aged Care Standards, which focus on safety issues relating to workers and also food safety (in turn improving resident safety). The employment of this resource person full-time for two years is estimated to cost approximately $140,000.

The company also undertook to seek and obtain ISO 45001 SHE (safety, health and environment) management system accreditation, and follow-up re-certification at specified intervals. To achieve this, the business’s SHE management system will be assessed by an independent expert third party. The estimated cost of this initiative was $11,000 per accreditation period.

In addition, the company will undertake site inspections in each of the aged care facilities where it operates in Victoria, as part of an Aged Care Quality Standards Audit Program. The total cost to the company of this element of the undertaking will be in excess of $30,000.

The caterer also committed approximately $60,000 to developing and delivering a training package to assist and educate others in the aged care industry about the International Dysphagia Diet Standardisation Initiative (IDDSI). Dysphagia is the medical term for difficulty swallowing foods or liquids. It can range from mild difficulty to complete and painful blockage, and is thought to affect approximately 40 – 50% of people in residential aged care facilities. It can cause dehydration, malnutrition and aspiration pneumonia, and can be associated with depression and deterioration in quality of life. The Dysphagia Diet Standardisation Initiative aims to improve the lives of people with this condition, through a focus on food consistency and related matters.

The company will promote the training package (including training material, video, competency assessments and supporting material) and make it available to other service providers in the aged care industry, at no cost. It will also require its Operations Managers, State Managers, Chef Managers and Catering Assistants to attend a training session and watch the video – at an additional cost to the company of $10,000.

Further, it will support The Lantern Project, which was established in 2013 with the aim of improving the food and dining experience for residents in the aged care industry. The Lantern Project is proposing the development of a new national Food Standards Code for the aged care industry, linking the current Food Standards Code with the Aged Care Quality Standards.

This is important because at present, food safety audits in the aged care industry are assessed against standards applying to large supermarket chains and fast food operators, despite the huge difference between retail operations and the aged care industry. The effect of this is that vulnerable persons including aged care residents have no right to choose what they consume. Giving back freedom of choice to residents is a fundamental principle of the Aged Care Quality Standards. The caterer’s support is expected to cost the company approximately $20,000.

As well, the business will make a $10,000 donation to Lifeline.

Since the incident, the company has also made other WHS improvements that are not part of the undertaking.

For more information about this enforceable undertaking, visit WorkSafe Victoria’s website.

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