A Whangarei rest home where a fatal morphine overdose was accidentally given to a resident will not be subject to an official inquiry, according to the Ministry of Health.
Whangarei coroner Max Atkins was critical of the staff and management of Maunu's Lady Jessica Rest Home following an inquest into the
death of resident Dorothy Emilie Robertson on April 23, 2001.
In his findings, released last month, Mr Atkins found Ms Robertson died after she was accidentally given another resident's morphine by caregiver Delia Siddells.
He stated medical reports pointed to the frail elderly woman probably dying as a result of a major failure by rest home owner Lesley Attwood to obtain medical advice urgently.
"Appropriate action would very probably have saved her life," Mr Atkins had said.
The coroner said the home's staff and manager had "failed badly on this occasion" and would need to look very closely at their procedures to make sure that they fully complied with their obligations.
However, the Ministry of Health, which has a policy of regular monitoring of all rest homes, has no plans to hold a ministerial inquiry, though it will continue to monitor the home.
Colin Feek, Ministry of Health deputy director general of clinical services, said ministry staff had visited the Lady Jessica home twice since the incident.
"The ministry is continuing to work urgently with the district health board and the rest home to ensure patient safety is assured," he said.
He said there had been an increase in the hours worked by a registered nurse at the home since Mrs Robertson's death.
The role of a registered nurse is expected to include education, supervision and competency testing of caregivers, who have the responsibility to administer medication to residents.
Any decision as to the future of the Lady Jessica's licence would be a matter for the Director-General of Health to consider.
Dr Feek said rest homes had not been legally obliged to report such incidents to the ministry in the past, but would under tougher new legislation which comes into force on October 1.
Under the Health and Disability Service (Safety) Act 2001, services, including rest homes, that would have been previously licensed will have to be certified and audited by the Ministry.
Ms Attwood declined to comment on the issue.
The inquest finding was not the first time concerns had been raised about the Lady Jessica.
In February 1989, three staff members complained about "intolerable" working conditions at the rest home, including concern about drug storage and dispensing.
A subsequent investigation into the home found the Lady Jessica had been unlicensed since it opened in December 1988, thereby operating illegally.
The rest home escaped prosecution and the Health Department granted it a temporary licence in April 1989 -- after Ms Attwood appealed a preliminary decision not to grant her a licence.
In July 1989 the department granted Ms Attwood a full licence as the rest home had "complied with requirements", including the installation of a drug cabinet and upgraded access.
Also in July that year, the Whangarei District Council granted the rest home a planning consent Ms Attwood had "not been aware was required".
- NORTHERN ADVOCATE (WHANGAREI)
A Whangarei rest home where a fatal morphine overdose was accidentally given to a resident will not be subject to an official inquiry, according to the Ministry of Health.
Whangarei coroner Max Atkins was critical of the staff and management of Maunu's Lady Jessica Rest Home following an inquest into the
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