A grieving daughter says her complaint about the treatment of her mother at a Whanganui rest home was unfairly dismissed by the Health and Disabilities Commission (HDC).
Joan Johnston raised concerns about the standard of care her mother received at Springvale Manor Rest Home before dying two weeks later.
She took her complaint to HDC and after some investigation was told no further action would be taken.
Ms Johnston said her mother had three falls within 24 hours - the first one she put down to an accident but the second two, she said, could have been prevented.
"I was called about the first one at about 10.30 at night - when I got there my mum was back in bed peacefully sleeping."
She said the registered nurse thought she'd had a stroke but was assured that she would be looked after and monitored every 15 minutes.
"She had a bell mat that was meant to alert the carers as soon as mum's feet hit the ground but they said it wasn't working and they would replace it straight away to prevent it from happening again."
The next morning Ms Johnston rang up to check in and discovered her mum had two more falls in the night.
"On all the incident reports the registered nurse and carers noted the bell mat wasn't working so it never got replaced but they told the commissioner they were working.
"I was angry that they had not notified me of the last two falls. They had assured me she was going to be looked after, I would have stayed the night with her if I had known otherwise."
On another occasion the registered nurse had advised her that if her mum was to be moved and treated she needed morphine.
"I was with mum when the carers were about to move her without morphine and I could see mum was in pain. I told them what the registered nurse had said and they weren't happy about it but they gave her morphine."
But Ms Johnston said it took 15 minutes to kick in and they barely waited 10 minutes.
"I heard mum screaming from the other room, like I've never heard her before."
In a letter from the deputy Health and Disabilities Commissioner to Ms Johnston it said: "As there are differing accounts about what happened with the equipment it is difficult to determine what role the devices had in your mother's falls."
It also stated: "There is a discrepancy in accounts regarding the administration of morphine and how soon after cares were provided."
The complaint was forwarded to the Whanganui District Health Board, as the funder, and HealthCERT, as the agency who monitors the standards of rest homes, but apart from a hard word no further action was taken.
While a Health and Disabilities Commissioner spokesperson said they could not comment on the case specifically, they did say every complaint about rest homes was taken extremely seriously.
"All residents have the right to receive safe services and care of an appropriate standard. HDC has a wide discretion to refer complaints to ensure that issues are considered and resolved in an effective and speedy manner."
"HDC understands that HealthCERT is liaising with the DHB regarding the ongoing monitoring of services provided at Springvale Manor Home."
But Ms Johnston said she felt like HDC sided with everything the rest home was saying even though the incident reports contradictedtheir account, and her concerns were not heard.
"I thought the commission would be more independent and they would have investigated more thoroughly to be honest."