A researcher from the Monash University made an effort that would eventually help improve quality of life for older adults residing in nursing homes. But it's been a hard road.

Several incidents at the home have been referred to police. A coronial inquiry into the 2008 death of a resident is underway, and others are expected.

The ICAC report found maladministration against five managers and staff and failures in clinical governance at Oakden, as well as incidents of rough handling of patients, excessive use of restraints, and injuries. The nursing home shut last year.

The work, led by Monash professor Joseph Ibrahim, touches on elder abuse, suicide and premature death in nursing homes, prevention of both intentional and non-intentional injuries, and the concept of 'dignity of risk' – in other words, allowing people in God's waiting room to live better.

"Premature deaths occur in older people," Professor Ibrahim says. "If you don't agree they're premature then you don't agree they're preventable, and if you don't believe they're preventable then you don't believe there should be any action. And if there's no need for the action, the system must be OK."

Autonomy and choice

In 2013, Professor Ibrahim co-published a paper in the Australasian Journal on Ageing outlining the concept of 'dignity of risk', in which old folks in nursing homes would be allowed more autonomy and choice in what they do.

It might be what they eat, drink, smoke or where they're allowed to go, and how they're allowed to go there. Inhibiting an individual's risk-taking can erode their dignity, according to Professor Ibrahim.

He agrees high rates of dementia in nursing homes (up to 60%) complicates autonomy and decision-making, but those with dementia have differing limitations, and most are able to indicate their wishes and preferences.

Their functional ability should and must be reassessed when care plans are updated to reflect their preferences.A difficult idea, but he and his colleagues maintain it's necessary and the right moral choice. The barriers – both intellectual and structural – are immense.

Marta Woolford, Ph.D. candidates from the Department of Forensic Medicine, says society's perception of aged care has to change from being a place of protection to a place where people actually live. "It should be an extension of your home," she says, "where you're supported in what you want to do."

That extends to staff, who need to see a nursing home as somewhere they'll also be supported in decision-making about residents. The family of residents should learn to alter their expectations.

"We can't move toward a conversation about people having choices in aged care if no one has a staff member's back when it goes wrong," says Professor Ibrahim.

Deaths in aged care

The team has spent the past five years going through coronial data on deaths in aged care facilities, nationally. There are 2700 facilities in Australia, housing about 170,000 elderly people.

Premature deaths are by suicide, falls, choking, clinical care or as a result of an 'unexplained absence'. They want to look more closely and better understand how dementia, depression, nutrition and dental health affects the lives of older people, and how these contribute to death.

Briony Murphy, Ph.D. candidates from the Department of Forensic Medicine, found that between the years 2000 and 2013, 140 nursing home residents took their own lives. The highest risk period is the first year in the home. Most were male – 70% – and 66% had been diagnosed with depression.

"Depression can be more difficult to diagnose in older adults, as they may themselves believe their symptoms to be a natural reaction to a physical illness or the life changes they're going through," Murphy wrote in an article for The Conversation.

The data showing the high number of residents with depression told the researchers that it's not a normal part of the ageing process but the result of other factors, including health deterioration (80% of those surveyed), isolation and loneliness (43%), and difficulties adjusting to life in a nursing home (30%).

The research revealed how little we still know about suicide in the nursing home setting, a surprise considering our ageing population and increased demand for aged care services, combined with the fact that older adults have the highest suicide rates in Australia and the world.

"I wanted to generate much-needed discussion about aging, aged care and dying in Australia, and improve the quality of care and quality of life for older adults residing in aged care facilities," Murphy said.

The researchers say a better understanding of how, where and when older people die in nursing homes is the first step towards reducing harm, improving quality of care and quality of life.