A frail elderly woman with multiple health problems was found critically ill at her home after her regularly scheduled support worker was unable to enter her house.
Access Community Health, who provided twice-daily cares and safety checks to the elderly woman, failed to ensure that the pensioner was safe, denying her the opportunity for earlier medical intervention, the Health and Disability Commissioner has found.
The elderly client, who had been deemed to be a high falls risk, lived on her own and relied on twice-daily cares from Access health.
A support worker would also carry out daily safety checks to ensure that the client was safe in her own home.
But one morning, the elderly woman did not answer her the door to a support worker.
The worker contacted Access' call centre, which followed the set procedure for when a client was not home, including calling the woman's house and next of kin.
Neither answered the phone.
"A call was made to the local hospital, but it advised that the woman was not a patient," a decision released today stated.
"The support worker was advised to move on."
That process would be followed the following afternoon and the next morning - when the support worker finally entered the woman's home using a neighbour's key.
There they found the elderly woman in bed, cold and unresponsive.
She had suffered a stroke and a significant cardiac arrest and was rushed to hospital.
"The events were considered terminal, and palliative care was commenced," the HDC decision stated.
"Mrs A passed away at 1.35am the following day."
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Deputy Health and Disability Commissioner Rose Wall's report found Access in breach of the Code of Health and Disability Services Consumers' Rights, for failing to have adequate procedures in place when checking on its client.
While the support worker followed the procedures in place, Wall was critical of Access' procedure followed when the client was deemed to not be home.
The policy had no escalation mechanism, nor was it different for clients with higher risk profiles, out of line with sector standards.
The elderly woman suffered from multiple co-morbidities including impaired vision, aortic valve stenosis, chronic obstructive pulmonary disease, impaired balance and breathlessness on exertion, but Access' policy did not reflect her high needs.
Walls recommended Access Community Health apologise in writing to the family, provide further training to call centre and support work staff on the process to follow when a client is not home and for the cases in which that procedure was followed to be randomly audited.
Clients that require safety checks should have their files flagged for special attention and important information for clients - such as spare keys - should be recorded, the HDC recommended.