An Auckland rest home has apologised and issued warnings to two staff members for "gross misconduct" after a resident's disappearance went unnoticed for 13 hours by caregivers who failed to make overnight checks.
Maree Wilkins, 85, disappeared from Leigh Road Cottage on November 7 where she had been receiving care for dementia.
She has never been found despite extensive land and aerial searches of bush and the estuary by police and community members.
That search was suspended at the end of November and police confirmed last week there had been no breakthroughs in the case.
The internal investigation report into Wilkins' disappearance, provided to the Herald on Sunday under the Official Information Act by the Waitemata District Health Board, reveals another resident went missing while living at Leigh Road Cottage but was found after six hours.
Leigh Road Cottage hadn't reported that incident to the DHB. The care home, which overlooks Whangateau estuary about 75km north of Auckland, is now being monitored by the DHB.
Wilkins was last seen at 5.30pm on November 7 when she was seen in the garden by a caregiver. According to the report, "Staff assumed that Maree had put herself to bed as usual without checking up on her. Until the end of the shift which was 11.15pm (the afternoon caregiver) did not check on Maree."
Evening staff took over shortly before 11pm and also failed to check on Wilkins throughout the night, out of fear opening the door would wake her. Upon realising she wasn't in her room at 5am they assumed she was in the lounge, the report says.
Wilkins' absence was noticed by a caregiver at 6.45am that day, prompting a building search. Police were alerted at 8am.
The report's summary of findings identified the top issue as the delay in realising Wilkins was missing. Staff hadn't followed policy and procedure by failing to make compulsory overnight checks.
Staff were unable to determine whether Wilkins was inside when the building locked down at 7pm and a lack of security cameras meant they couldn't determine when she had left the premises, or how.
According to the report a similar incident happened when a resident went missing for six hours. A family member visiting another resident had let a male resident out, and he was found down the road, unharmed, hours later.
Visiting hours were consequently implemented from 9am to 5pm and visitors outside those hours had to be escorted in and out, the report said.
Since Wilkins' disappearance the rest home had trained staff to address safety issues, changed handover procedure, and instigated more regular overnight checks on residents which had to be signed off by staff.
Locks had been upgraded on gates, a second gate would be built, and a camera had been installed- although they are not required.
Wilkins doesn't have family in New Zealand but her Australia-based niece Dale Fewings told the Herald she had read the report and was forgiving of the actions taken by rest home staff. Wilkins was a light sleeper and she said she understood staff were hesitant to open her door throughout the night.
"Although the staff's good intentions are understandable, I can see that this resulted in Maree not being noticed missing sooner ... I agree that a check that she was actually getting ready for bed would have been expected. We all realise, now, that a camera on the gate would have been the answer to many questions regarding Maree's disappearance."
Leigh Road Cottage director Dennie Chiew said Wilkins' disappearance had been devastating for staff and said Wilkins was a very intelligent woman who had likely "seized an opportunity" and taken off.
"Obviously it's a human error for not checking her overnight. It's an unfortunate thing that has happened. No one wants this to happen. We try our very best to look after our residents, and we have been. I know there is probably a negative feeling in the community, but we try out best to provide the best care.
"I've given a gross misconduct warning to two staff."
Kate Sladden, the DHB's Funding and Development manager for Health of Older People, said its quality and monitoring manager would meet with the facility regularly to ensure corrective actions were taken.
The rest home was last audited in January and that audit would be made public on the Ministry of Health's website when finalised.