The family of an Indigenous man who died on the footpath outside his eastern Victorian nursing home after a suspected fall is pleading for answers about the lead-up to his final moments.
Warning: Aboriginal and Torres Strait Islander readers are advised that this article contains images and the name of a person who has died.
Dennis Miller, 70, was found in a pool of blood and vomit, and with facial wounds, outside his room at the Royal Freemasons aged care facility at Moe, in Gippsland, in May.
The Victorian coroner is investigating the deaths of three other former residents who died at the same nursing home between July 2020 and November 2021 with the federal regulator, the Aged Care Quality and Safety Commissioner, also investigating the facility.
But it is Mr Miller's death that has sparked calls for a national register of all aged care deaths in Australia.
'Significant' injuries
At 8:45am on May 15, 2022, a nurse from the Royal Freemasons aged care facility at Moe rang Mr Miller's daughter, Samantha Mowatt, and left a voicemail.
In the recorded message, the nurse informed Ms Mowatt of her father's death, saying, "We found him dead outside on the ground".
What Ms Mowatt saw when she arrived at the nursing home deeply shocked her.
She said her father had "significant facial injuries" and injuries on his arm and leg.
"When we looked outside of his room, there was a significant amount of blood on the concrete, and staff had already started to try and wash that off the concrete," she said.
"And I just said to my husband at that time, 'Something's not right'."
That feeling has not left her, as she has fought to find out the truth about her dad's death.
History of falls
Mr Miller was a Wurundjeri man, and father of three, grandfather of 13 and great-grandfather of nine, who moved back into Royal Freemason in April last year.
Prior to his retirement, he worked as a motor mechanic, national fleet manager, and dairy farmer.
He loved model trains and showing them to his grandchildren, who called him Pa Pa.
His daughter said he often looked after the other nursing home residents who had dementia, or helped staff by setting the dinner table.
He had experienced a traumatic start to life, after he was placed in care as a four-year-old and suffered abuse at the orphanage where he lived.
He also had significant health problems, including a weakened heart muscle, prostate cancer, and chronic liver failure from a history of alcoholism.
Mr Miller had a history of falls, which was one of the reasons he moved into residential aged care.
In the 13 months prior to his death, his progress notes, written by staff as a legal record, show he had eight falls.
In January, after Mr Miller fell and hit his head in his room, a physiotherapist recommended changes to his care because "he's prone to falls and prone to fracture".
Photos taken of resident
Another distressing part of Mr Miller's death for his family was finding out Royal Freemasons staff had taken photographs of him while he lay face down on the concrete in his own blood and vomit.
In one of them, Mr Miller had a blanket draped over him while still face down on the concrete.
"I can't imagine why you would want to take photos of a person in that situation," Ms Mowatt said.
"Why wasn't he being looked after?"
A letter sent to Ms Mowatt in September 2022 by Royal Freemasons acknowledged and apologised for the "photographs of Mr Miller being provided to you and the family".
"This should not have occurred," the letter said.
"The photographs were taken by staff in accordance with our policy to take them as evidence where the circumstances suggest the matter may be the subject of further investigation, for example, by the coroner or WorkSafe."
Question over care
The family also has questions about whether Mr Miller was adequately cared for in the hours before his death.
The only file note written by staff the day before he died was at 11:43am, documenting medication administered at 9am.
However, four progress notes were written in the hours after he died, from 8:52am to 10:54am, documenting interactions with Mr Miller in the 12 hours before his death.
This included giving him two doses of oxycodone, a prescribed opioid pain-relief medicine, at 9:30 pm and 11pm.
Staff observed in the notes Mr Miller had been drinking alcohol and "appeared intoxicated".
"To give a large amount of medication on top of that would put someone at a risk of having a fall," Ms Mowatt said.
The Therapeutic Goods Administration advises oxycodone should not be taken with alcohol.
An hour before Mr Miller died, a night shift nurse reported at 7:03am that he appeared "comfortable and safe overnight" but the entry included the notation "remove reason: incorrect detail".
When Mr Miller was found lying on the concrete at 8:05am on May 15, staff wrote they observed a "small amount of blood and vomitus" on the floor.
But sources, who did not wish to be named, have told the ABC nurses were alerted by the call assist button 25 minutes earlier, and an off-duty nurse was asked to return.
The off-duty nurse checked Mr Miller for signs of life and asked for an ambulance to be called.
Mr Miller had a weak pulse, but died at 8:15am when an ambulance was called.
Calls for aged care death reporting
Professor Joseph Ibrahim from Latrobe University's Australian Centre for Evidence-Based Aged Care said there should be a transparent register of all deaths in aged care homes.
It was something he lobbied for in his submission to the Royal Commission into Aged Care, which handed down its final report last year.
He compiled case studies from all aged care deaths investigated by state coroners across the country to educate staff in the sector.
In the three months to September 30 this year, 232 "unexpected deaths" in nursing homes were reported to the Aged Care Quality and Safety Commissioner.
But Professor Ibrahim estimated between 50,000 and 60,000 people died in aged care each year and said the definition of "unexpected deaths" under this scheme had never been properly defined.
"Every death should be registered in aged care in a central place that can be analysed … so we're able to keep improving the system," he said.
Coroner investigation confusion
Ms Mowatt said there was also confusion over whether her dad's death was reported to the Victorian coroner.
Under legislation, a death is reportable to the state coroner where the death is in custody, unexpected, unnatural, violent, a result of accident or injury, or involving a mental health patient.
When Mr Miller's doctor, Robert Birks, signed Mr Miller's death certificate, he noted "cardiac arrest" as his cause of death, which is not reportable.
But according to the death certificate, Dr Birks did not see Mr Miller's body.
"If I've completed the death certificate for a patient then I will have detailed knowledge of the circumstances surrounding death," Dr Birks told the ABC.
Dr Birks said he did not think he was "legally allowed to answer questions directly about [Mr Miller's] case", and the ABC is not inferring Dr Birks acted improperly.
In July, when Ms Mowatt learnt her father's death would not be investigated, she wrote to the Office of the Victorian Coroner and put in a complaint to the Aged Care Quality and Safety Commission.
"The community has a right to understand what has happened, so that prevention processes can be put in place to stop similar deaths," Victorian Institute of Forensic Medicine Deputy Director David Ranson said.
A spokeswoman for the Victorian coroner's office said it was "currently reviewing available evidence to determine if the death is reportable" and if an investigation should be initiated.
In a statement, Royal Freemason's chief executive John Fogarty said the Aged Care Quality and Safety Commission and the Victorian coroner were investigating Mr Miller's death, and it would cooperate.
"The staff on duty at the time of Mr Miller's death followed appropriate protocol to inform police who attended and police made the decision to refer the death to the coroner," Mr Fogarty said.
"It would not be appropriate to comment further until these investigations are complete."
But Mr Miller's family is facing Christmas without him and wants action by authorities to uncover how and why he died.
"At the moment, there's no closure," Ms Mowatt said.
"He's not here and we don't understand why."
