A systemic investigation was conducted by the Office of the Health Ombudsman (the OHO) into the management of patients admitted for acute care within a public hospital experiencing BPSD and/or delirium.

The investigation was initiated in response to a complaint about a patient being physically assaulted by a co‑patient experiencing BPSD.

Wider learnings and recommendations for service improvements

To improve management of patients with BPSD and/or delirium, the investigation identified the following opportunities for health service improvement:

• Implement specialist geriatric models (dementia-focused units and support teams) to improve assessment, care coordination and discharge planning, reduce behavioural escalation and length of stay, and improve outcomes.
• Provide dementia-friendly infrastructure to support safer care for patients with cognitive impairment and the staff who care for them.
• Ensure clinical and nursing staff are trained and competent to identify, assess and manage cognitive impairment and respond to dementia-related behaviours.
• Strengthen governance so multi-factorial delirium is considered and inappropriate or excessive pharmacological management is avoided.
• Embed mechanisms to report, assess, escalate, review and learn from occupational violence incidents.

Read the snapshot report (PDF 124KB)