How does a rest home resident end up with maggots in his wounds? Nicholas Jones investigates.
As a father he taught them to cook shellfish over a corrugated tin camp fire.
Now 86, a failing heart had narrowed Evan's world to a strange room smelling of excrement and dotted with flies.
"Dad was at the stage where he wasn't really interacting a lot. He might mumble and he hung his head all the time," recalled his daughter, Corina, who asked for surnames to be withheld.
"When my brothers were there we would just sit there and chat. He could hear us. Every now and then if my arm was on the chair he would reach out and pat it."
He found his voice when Corina and her brother spoke of the need to keep raising problems with staff at Pukekohe's Palms Lifecare rest home.
Nothing had been done about the flies, for example. As they spoke, Evan lifted his head and locked eyes with Corina.
"He said, 'They know when you are coming, change your time.' Then he put his head back down. My brother and I just looked at each other."
When Corina's brother arrived the next morning a nurse was soaking Evan's feet. He groaned and cried as tweezers plucked maggots from under his big toenail and between his toes.
"My brother could see them in the water," Corina said.
"Crawling up the side of the bowl."
A heart-wrenching decision
In childhood Corina and her siblings often fell asleep to a sewing machine's whir.
"Mum and dad tried to get farmhouses as the rent was cheaper," she said. "So if mum milked morning and night, dad would go to work during the day. My mum also sewed for a company at night, so we would all go to bed as kids and you would hear her sewing.
"We didn't have a lot, but we didn't know it back then. We were all so loved."
Evan worked as a mechanical engineer. He loved to tinker and invented contraptions, including a drilling rig that could be helicoptered into remote sites, and an early model road sweeping truck.
As well as their own kids he and his wife fostered many children over the years, working with social welfare and police.
The couple later lived with Corina for 20 years, helping raise grandchildren and changing tack after a diagnosis of cancer and then Parkinson's disease.
"Mum's dream was to run her own cafe. So they got some money together and opened one in Pukekohe. They did that until mum's Parkinson's meant they couldn't anymore."
Corina lost her mother four years ago. Evan loved the open road, she said, and thought nothing of driving his Chevy to Napier and back on a day off. But age caught him too, and after a second stay in Middlemore Hospital a family conference was called.
Their patriarch had an end-stage heart condition, pneumonia, signs of mild dementia and required a catheter. His heart struggled to pump blood to badly swollen legs. Ulcers developed and skin peeled away.
"His wound care was way out of my league. I said to the doctor, my family and dad, that I just couldn't do it anymore. I'm scared to leave him and go to work," Corina said.
"He was heartbroken, I know that. And I live with the pain of no longer being able to care for him."
Arrival at Palms Lifecare
Moving into aged care is something more of us will face. There are about 83,000 New Zealanders aged 85 or older – a number forecast to rise to up to 284,000 by 2043 and 467,000 by 2068.
Evan qualified for terminal care funding, meaning he wasn't expected to live longer than six weeks.
Soon his family had cause for worry. One Monday Corina found him soiled, with mess around the room. She said it took 40 minutes to get the attention of a staff member and nurse, and insist they shower Evan and clean the room.
Corina had to leave, but made sure her brother checked in the next day. He rang to say the room stank, and their father had faeces on his hands and up his back, with mess still on a chair and floor. He complained to the duty nurse, and again after still smelling faeces after a care assistant had helped his father.
Corina went in the next afternoon and said she was confronted by the same scene: "there was still faeces on the chair. Faeces on his clothes. On the floor."
After another call to the nurse Evan was finally taken for showering, she said, and his bedding changed.
Pain relief was also a problem. Evan was mostly given paracetamol, and Corina said he lacked capacity to ask for stronger medication.
She believes he would have been in agony during movement and dressing changes – when in Middlemore he would cry out when a specialist gently blew on his legs to test his pain.
The same wounds wept which, in the middle of summer and with no air conditioning, attracted flies. The family bought a fan and an automatic fly spray, Corina said, after staff did nothing.
"Sometimes they would try and put a sheet on him, but the sheet touching his skin hurt and he would pull it off."
When her brother saw the maggots he demanded a doctor, but was told the GP was busy that day. Corina arrived in the evening and said she had to insist on at least daily dressing changes and better pain relief. She was told the GP couldn't come for another two days.
In the meantime, she tried to find somewhere else for her father to go. That wasn't easy, something she later raised with the DHB.
"I had to go through the social worker – so it wasn't going to happen that week or the next. How are [Palms staff] going to treat him once they know we want him moved?
"[The DHB] said they couldn't take him to hospital. I should have somehow wheeled him out, driven down the road and called an ambulance."
"Very upset @ 10.00 hrs"
Distressed, on March 7 Corina rang into Radio Live talkback, which led to a visit by a clinical specialist nurse from Counties Manukau DHB. The DHB's findings ultimately substantiated five failings.
"The soft tissue care plan does not consistently document dressing changes so there may have been a period of time in the days before the maggots were found when the resident's wound was not assessed and evaluated," the report noted.
That meant "the eggs could fully develop into maggots without being disrupted".
Dressings were to be done every other day. However, they were only documented on February 6, 8, 11, 18, 19, 25 and 28.
On February 28 a file entry states the dressing should be reviewed in two days. Whoever wrote it underlined the instruction, but the next recording was March 4 – two days before the maggots were found.
Seven to 10 maggots were removed from Evan's toe. Later that day a nurse washed his lower legs and picked out another four to five. The next day another was found.
Evan apparently wasn't showered around the time his family discovered him covered in faeces, and the DHB found it concerning "if this episode did occur" it didn't lead to a continence review.
He fell twice and had one "near miss fall" during his stay, resulting in a forehead laceration and bruising. Care plans, evaluations and neurological observations weren't properly carried out in response.
Palms' policy requires a registered nurse to document the progress of residents in hospital-level care at least daily. However, there were 10 days when no note was made, including two lots of successive days.
There were at least 12 days when only a caregiver made notes. When both a caregiver and nurse made entries, they could contradict.
For example, a caregiver wrote that Evan had stayed in the lounge all day without issue. The nurse entry recorded him as "very upset @ 10.00 hrs", taking his dressing gown off, and convinced staff were trying to kill him.
A fluid balance chart wasn't properly updated, and there was no evidence vital signs were watched as required.
Corina's father weighed more than 85kg on arrival in December. By January he had lost 9.5kg, but there was no record of such a drastic drop being evaluated.
No weight was recorded for February. In the early hours of March 9 he died, weighing 70kg.
A watchdog with bite?
Corina was disappointed the DHB couldn't fully substantiate two aspects of her family's complaint, including that Evan's condition deteriorated over a two-week period, and that they couldn't properly discuss this with staff.
She's sure her father suffered a stroke but said the nurse brushed off her concerns and request for a doctor. Photos clearly show a serious deterioration, she said.
As Evan approached day 10 of his Middlemore stay the family learned the term "bed blocker", a description for the mostly elderly who can't go home, but need to be moved on. DHBs fulfil a watchdog role over private rest home providers they also rely on to outsource care to.
Corina's family received the DHB report via Heritage Lifecare, the company that owns Palms and 25 other rest homes, including the country's largest rest home and hospital.
A Heritage representative gave the family a formal apology in person, and a copy of a media statement the company would release if necessary.
A spokeswoman for the company, now part-owned by Australian private equity firm Adamantem Capital after a deal in April, said existing procedures weren't followed and appropriate disciplinary action had taken place as a result.
"The company obviously deeply regrets the incident that took place but is confident - and this is supported by the DHB independent review - that such an incident does not occur again."
Executive chairman and founder David Renwick previously told the Herald shortcomings weren't related to staffing levels or training. Despite that, a corrective action plan agreed with the DHB included extra education for care and cleaning staff.
Asked about this and other issues, Renwick said in a statement: "we take the finding of these investigations extremely seriously and have reinforced to all staff at Palms and throughout the wider group the need to adhere to existing and proven procedures to deliver the very best care, in line with Heritage Lifecare's standards".
Counties Manukau DHB is confident residents at the 120-bed Palms are safe. A spokeswoman said it will keep working with Palms to "ensure an appropriate level of care". The DHB is satisfied changes are being implemented.
"Counties Manukau Health does not take a punitive approach to complaint management, preferring a collaborative approach to ensuring that corrective actions can be robustly implemented and sustained," the spokeswoman said.
DHB representatives met with Corina on Tuesday, following Herald inquiries. She is confident the DHB will take another look at the unsubstantiated findings.
"They are sincere personally and professionally in relation to this," Corina said. "Broadly, it sits with our Government to facilitate the changes required. The DHB is restrained by funding and resources."
A broken pledge
Rest home certification audits happen every 1-4 years, and a spot audit occurs around the middle of that period.
The Herald has reviewed more than 1000 audit reports for the country's 651 facilities, and found that since 2016 a third had shortfalls related to resident care.
Some of the failings outlined in the DHB report on Palms Lifecare come up time and time again in audits for other facilities.
The way Evan's wounds were treated wasn't good enough; almost 100 other facilities have had shortfalls in wound care.
He dropped almost 10kg but no care plan was developed; auditors found 30 other rest homes with the same failing.
Falls were not followed with the needed neurological observations; since 2016, 36 facilities failed to do the same.
There is concern the auditing process doesn't pick up problems. The Human Rights Commission views the auditing system as "inherently limited", and Consumer NZ wants it beefed-up.
The last audit for Palms Lifecare was in June 2017, with no shortfalls identified – effectively the best result auditors can give.
Jessica Wilson, Consumer NZ's head of research, said that showed residents could suffer unless a complaint was made.
The Herald has reported on complaint investigations at other facilities, including a lack of food and incontinence supplies, and a woman left shivering in a urine-soaked bed.
A 95-year-old slept in a recliner chair for 24 days because an adjustable bed wasn't available.
Consumer, Age Concern and Grey Power want reforms including voluntary care guidelines, which include staffing ratios, to be made mandatory and the establishment of an Aged Care Commissioner – steps Labour supported in Opposition.
A week before the election David Clark, now Health Minister, said an Aged Care Commissioner would be provided for in a Labour-led Government's first Budget.
That was delivered this month with no funding earmarked.
Associate Health Minister Jenny Salesa said in a statement that aged care was important to the coalition, but any future changes would be decided by all three parties – Labour, NZ First and the Greens.
"This is just one Budget and we will be working together to find ways to improve aged care."
Salesa said a review of mandatory Health and Disability Service Standards which rest homes are audited against had started, as had a review of how the sector was funded.
Care workers will get a second wage increase on July 1 after the Kristine Bartlett pay equity case, which Salesa said was expected to reduce turnover, improve qualification and therefore provide better care.
A wide-ranging review of the health system, announced on Tuesday, will include how the ageing population will affect services and care. A final report is not due until 2020.
About 36,000 people are in rest home and hospital care, and new facilities are being built across New Zealand.
Corina wanted to speak out to make sure "the person who takes dad's bed doesn't have the same thing happen to them".
"Dad didn't want to go in there. He was petrified. We promised he'd be looked after."