A young disabled man died after instructions for his care were ignored, and he was left alone in bed where he slouched over and stopped breathing.

The man's caregiver and the residential care home where he was staying failed to provide services of an appropriate standard, the deputy Health and Disability Commissioner Rose Wall found in a report released today.

The 20-year-old man stayed at the residential care home three nights a week, and required 24-hour care because of acute obstructive sleep apnoea, cerebral palsy and epilepsy, the report said. He was unable to walk and used a wheelchair.

At the time of his death, the man was staying at the care home and was cared for overnight by a sole caregiver, who was also caring for three other clients with complex needs. The caregiver was to remain awake during the night and check the man frequently, as well as follow the man's personalised night-time care plan.


After going to bed at 11.10pm, the young man woke up at approximately 3am. The caregiver left the man on his back in bed for 10-25 minutes before transferring him to his wheelchair. At approximately 5am, the caregiver transferred the man from his wheelchair back to his bed, with the bed raised at the head end, in order to perform the man's personal cares, the report said.

The caregiver said went to the en suite bathroom to wet a flannel and, when he came back, the man had moved so that he was diagonal on the bed and was struggling to breathe.

The man then stopped breathing, and the caregiver called 111. Under the guidance of the call handler, the caregiver performed CPR until two ambulances arrived at 5.33am. The man was taken to hospital where he died at 8am.

In her report, Ms Wall said the caregiver "failed to comply with the man's night-time care plan, in that he did not attach the man's shoulder harness after transferring him into his wheelchair, or place a pillow under the man's head and shoulders after transferring him back to bed to perform personal cares".

It was unacceptable that the caregiver ignored instructions in the care plan, Ms Wall said, finding the caregiver in breach of the man's rights under the health code.
The residential care home also breached the code, she said, as its care planning for the man did not meet the accepted standard.

"The man had complex needs and it was important that his care plans contained up-to-date and detailed information for staff to refer to. This was particularly important as several different caregivers provided care to the man, at times in isolation with sole responsibility for his care," Ms Wall said.

The residential care home also breached the code because it did not have an adequate system in place to ensure the caregiver had accessed or received information and training provided during house meetings, and because the hours the caregiver was allowed to work following a previous disciplinary process put at risk the clients he cared for, she said.

Ms Wall was also critical of the residential care home's monitoring of the caregiver's performance.


The residential care home made a number of changes to its service following the man's death, the report said.

Ms Wall recommended that the caregiver and the residential care home apologise to the man's family, and that the residential care home conduct an internal audit of its clients' care plans, review the responsibilities of the "awake" night shift, and seek external expertise to review the adequacy of its staff training programme.

Neither the caregiver nor the care home was named in the report, but the home was operated by Creative Abilities and Associates Ltd.