A woman in her 60s who had not left her home in a year died from a bacterial skin infection after delays to escalate her serious condition.
"This has been a huge loss for my family. Since my Mum's passing things will never be the same again as each day I can see nothing but the pain and hurt in my family," her grieving daughter told the Health and Disability Commission (HDC).
Today, the deputy commissioner Rose Wall released a report finding the community support provider - Access Community Health Ltd (Access) - and one of its nurses in breach of the Code of Health and Disability Services Consumers' Rights for multiple failures in the woman's care.
The findings of the HDC's investigation come more than three years after her death.
Names of those involved were not included in the report, citing privacy reasons.
In the months leading up to the woman's death, Access support workers raised concerns on multiple occasions about her deteriorating skin condition.
But the deputy commissioner criticised Access for not having 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," Wall said.
Her primary caregiver was her husband, and she received two visits a day home from Access' support workers.
The deputy commissioner said this case highlighted the importance of coordination by all health service providers involved in a consumer's care.
Their respective roles and responsibilities needed to be clearly understood and communication channels needed to work effectively so that they were responsive to the person's changing needs, Wall said.
"This is particularly important in situations where the consumer has comorbidities and is at risk of becoming seriously unwell over a short timeframe."
Wall was also critical of the clinical nurse manager for not addressing the health concerns
escalated from support workers, and not making clinical notes in the woman's file.
She recommended Access undertake the following changes:
• Review its system for monitoring comprehensive reports and the training provided to support workers to respond.
• Undertake a nationwide audit against documentation policies and standards and review the training provided to staff on this issue.
• Provide a written apology to the woman's family.
Wall also advised the nurse to 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.
In the HDC report, Access said it was very sorry that it did not get everything right.
It said: "Access wishes to acknowledge the very tragic and sad circumstances surrounding [Ms A's] death. We are truly sorry that [Ms A] died and that her family have lost a much
loved and dear partner, mother, grandmother and great-grandmother."