Coroner casts doubt on claims over Bodington Nursing Home death

The daughter of an elderly nursing home resident who died after being injected with morphine has told an inquest a nurse falsified the records to hide the fact the dose was too high, and that staff often failed to follow procedures relating to the drug register.

But the veracity of the woman’s claims has been called into question, with the coroner describing the falsification claim as “a bit of a stretch”.

Sybil Zimmerman died aged 84 on May 15, 2011, after spending about 12 months at the Bodington Nursing Home at Wentworth Falls.

The inquest into her death at the Coroner’s Court in Glebe has heard that, shortly before Mrs Zimmerman died, a GP had prescribed her small doses of morphine for relief from pain linked to various health problems, and that these were administered regularly for a number of days.

When Mrs Zimmerman’s daughter Michelle Zimmerman visited her, she allegedly found her mother in a comatose state, with her eyes open but not responding.

Ms Zimmerman, who spent hours caring for her mother at the home each day, claims the nurses refused to act at this point, stating she was dying as a consequence of her pre-existing health problems and nothing could be done.

Mrs Zimmerman died in the Blue Mountains District Hospital a few days later.

The central focus of the inquest is whether she was injected with a 10-milligram dose of morphine — an inappropriately large injected dose for someone in her condition — or a five-milligram dose.

The nursing home denies the morphine dose was too high.

Last Thursday, Ms Zimmerman told the court that, on May 12, the registered nurse who administered the dose, Rosemary Chaplin, rang her to say her mother had not woken up properly.

“She called me at 11.30 in the morning on May 12 after my mum hadn’t woken up properly from the injection and said: ‘I should have only given her five milligrams not 10,’” Ms Zimmerman, who is also a registered nurse, told the court.

“Did you take it that she had made a mistake?” counsel assisting the commission, Patrick Griffin, asked.

“No, I believe it was an apology for giving my mum too much morphine,” she replied.

“But she didn’t say ‘I’m sorry’ did she?”


Ms Zimmerman also told the inquest that the relevant entry in Bodington’s drug registry had subsequently been falsified to indicate that only five milligrams had been administered.

This allegation is also denied by the nursing home.

She said the register had been filled out after the dose had been given rather than when the morphine was taken from the drug cupboard as is required by law. 

This was despite the fact that two people had signed the register — Ms Chaplin and a carer, Mary Pinkerton.

Ms Zimmerman claimed that staff shortages at the home meant that staff often filled out the register after the medication in question had been administered without taking much notice of what they were signing.

“Schedule 8 drugs were regularly given without a witnesses,” she said, as nurses in the gallery gasped in indignation.

“It was seen often. It’s got to do with workloads, it’s a workload issue,” Ms Zimmerman said.

But Deputy State Coroner Hugh Dillon and Mr Griffin expressed doubts about whether this was a realistic explanation.

“Do you recall ... that a registered nurse, if found to have falsified a medical document, could be found guilty of professional misconduct and deregistered?” Mr Griffin said.

“Are you inviting his honour, under oath, to reach a determination that Ms Chaplin deliberately falsified the drug register?”

“Yes,” Ms Zimmerman replied.

Mr Dillon declared: “I think it’s incredibly admirable that you put so much time and effort into caring for your mother, but it does seem to me to be a stretch to ask us to believe that this document was falsified.”

The inquest has heard previously that the matter had previously been investigated by the Health Care Complaints Commission, the Department of Aged Care and the Nursing and Midwifery Council.

While the departmental investigation found that staff at the home took insufficient steps to identify whether Mrs Zimmerman was unconscious, neither that investigation nor the other inquiries supported the claim that she died from an overdose or that this was subsequently covered up.

The evidence in the hearing concluded last week and the matter has been adjourned for final submissions to the coroner in March.

— Sydney Morning Herald