Inadequate care blamed for man's death

A mentally ill Southland man who died of a bacterial infection did not receive adequate support from his carers, the Health and Disability Commissioner has found.

Kenneth Keen, who suffered from schizoaffective disorder and mixed personality disorder, died of acute bacterial meningitis in his Invercargill flat in February 2006. The infection was a complication of his long-standing diabetes.

The 37-year-old had moved out of residential care two-and-a-half months before his death and received day-to-day in-home care from the Patients Aid Charitable Trust (Pact) , under contract to the Southland District Health Board.

In the months leading up to his death, Mr Keen had expressed concerns about his wellbeing.

He told carers he was worried about his ability to pay rent and buy groceries . He also said he was anxious about the availability of his diabetes medication and the lack of a landline or cellphone at his flat.

Mr Keen was twice admitted to Southland Hospital with high blood sugar levels and vomiting. On those occasions his carers had arranged for him to seek medical help, but a support worker who visited Mr Keen the morning before his death did not deem medical assistance necessary.

Mr Keen had been left unsupervised for over 36 hours before his semi-naked body was discovered by his parents.

"We found the flat to be in a dreadful state with vomit and urine on the carpet," they said.

"As a family we are particularly sad that Kenneth died alone in his flat without basic medical help."

In his report, Health and Disability Commissioner Ron Paterson found Pact had breached the Code of Rights by failing to fulfil its responsibilities and provide reasonable care.

Mr Keen had received only 129 of 219 scheduled visits, and records were inadequate .

Support staff should have alerted health professionals about Mr Keen's illness, the Commissioner said.

Southland DHB was also found to have breached the Code of Rights by failing to a dequately review the level of care provided by Pact.

Subsequent to Mr Keen's death, both Pact and the Southland DHB have conducted internal reviews and established a Memorandum of Understanding.

The commissioner recommended that both parties apologise to Mr Keen's parents, and report back to the commission on improvements they had made subsequent to their internal reviews.

Pact chief executive Maria Carr said the organisation provided day-to-day mental health care rather than medical care.

"We accept that reporting of the person's condition to health care providers falls within this, but this cannot occur every time a patient is unwell if that is the norm for the patient."

Southland DHB chief executive Brian Rousseau said its mental health services had been improving continuously in the two-and-a-half years since Mr Keen's death.

Both providers had sent apologies to Mr Keen's parents.

- NZPA