Deputy Health and Disability Commissioner Rose Wall today released a report finding a community support provider and
nurse in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failings in their care of
a woman with a skin condition.
The woman, in her early sixties at the time of these events, suffered from a number of health conditions including a
history of skin infections. She had not left her house in over a year due to limited mobility. Sadly, she passed away
from a bacterial skin infection.
While the woman’s primary caregiver was her husband, she received daily home and community support from Access Community
Health Limited (Access). In the months preceding her death, Access support workers raised concerns on multiple occasions
about her deteriorating skin condition.
The Deputy Commissioner was critical that Access did not have a reliable system for support workers to raise concerns,
and that concerns raised were not escalated or actioned.
"These service failures contributed to a delay in her receiving a review of her deteriorating skin condition, and
opportunities were missed for her to receive the clinical care and intervention she needed," Ms Wall said.
"This case highlights the importance of coordination by all health service providers involved in a consumer’s care, that
their respective roles and responsibilities are understood clearly, communication channels work effectively, and they
are responsive to the person’s changing needs."
"This is particularly important in situations where the consumer has comorbidities and is at risk of becoming seriously
unwell over a short timeframe," she said.
Ms Wall was critical that the Clinical Nurse Manager did not address the health concerns escalated from support workers,
and did not make clinical notes in the woman’s file.
Ms Wall recommended that Access review its system for monitoring Comprehensive Reports; review the training provided on
responding to support workers’ reports; undertake a nationwide audit against documentation policies and standards;
review the training provided on documentation; and provide a written apology to the woman’s family.
She also recommended that the Clinical Nurse Manager report to HDC on her reflections and the changes to her practice as
a result of this case; undergo further education on the subject of documentation; and provide a written apology to the
woman’s family.
The full report on case 18HDC00779 is available on the HDC website.