Welcome to the first issue of 2019. This will be a busy year for all our readers with the Royal Commission and the introduction of the new standards for accreditation.
This edition focuses on one case with so many issues it is almost too difficult to comprehend. Each gap in care probably would not have led to the resident’s death, but together, the combination was fatal.
The case exemplifies the complexity of issues confronting the Royal Commission and highlights that improving aged care requires an approach that involves the whole community as evident by the recommendations made by the coroner to multiple organisations.