Deputy Health and Disability Commissioner Rose Wall today released a report finding a rest home in breach of the Code of
Health and Disability Services Consumers’ Rights (the Code) for a number of serious oversights in the care of a woman in
the final months of her life.
The woman was admitted to the rest home following an admission to a public hospital. She had several wounds, including
ulcers, pressure wounds and skin tears, and was understood to require hospital-level care from the rest home.
The management of these injuries was found to be lacking. There were delays in seeking specialist advice, as well as in
the treatment and recording of injuries. The woman’s pain management was similarly found to be "inconsistent, irregular
and not proactively managed".
The rest home described its staff as being under significant pressure. It noted that at the time there were both changes
in management and staff on leave. However, while there were deficiencies in the care provided to the woman by staff, Ms
Wall considered that these deficiencies could be described more accurately as "systemic issues for which [the rest home]
bears responsibility".
Ms Wall considered that the care provided by the rest home was inadequate.
"[The rest home] had a duty to provide [the woman] services with reasonable care and skill. This included responsibility
for the actions of its staff… and an organisational duty to facilitate the continuity of care."
Ms Wall recommended that the rest home provide additional educational resources and training for its staff, and review
its wound management policies. In accordance with Ms Wall’s recommendation, the rest home also apologised to the friends
and family of the woman.
The full report for case 17HDC01449 is available on the HDC website.