A woman in her 80s died from sepsis after rest home staff failed to properly assess her for four days and did not call 111 immediately after she was found unconscious.
During the four days, the woman had suffered confusion, constipation, pain, and urinary incontinence until she finally lost consciousness.
By the time the woman was rushed to the hospital, it was too late - she died from sepsis and cellulitis.
Today, Bupa New Zealand was found in breach of the Code of Health and Disability Services Consumers' Rights for failing to appropriately manage a woman's care when her condition rapidly deteriorated.
Deputy Health and Disability Commissioner Rose Wall was also critical of a nurse for failing to manage the emergency situation appropriately when the woman lost consciousness.
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"The various nursing staff involved in her care should have been alert to changes in her condition and reacted more rapidly to new symptoms as they manifested," Wall said.
In the report, the nurse at fault said she thought the family was saying goodbye and that they wanted her to leave.
"I sent the carer back and left, leaving almost 10 family members with [the woman]. Before leaving the room, I definitely made sure [the woman's] airway was not obstructed. I regret now that I didn't immediately call 111."
The family of the woman said in the report there was no nursing staff present and over the next few minutes multiple family members began to arrive.
"I pushed the call bell and then in frustration used the emergency bell. It took far too long to obtain a nurse. Finally, after perhaps 10 minutes or maybe a little less I had a nurse in the room. The nurse was very competent once present and was of great help filling in the gaps."
The family said they had often witnessed her mother waiting 15 minutes or longer for someone to answer her call bell to assist her with toileting.
Bupa said it accepted full responsibility that the woman's care needs were clearly not identified by staff at this time and apologised unreservedly to her family for this.
Wall recommended that the rest home provide a written apology to the family, schedule specific education sessions for the facility's nursing staff, use an anonymised version of this case as a case study to encourage staff reflection and discussion, and review its policy on clinical emergencies.
Since the woman's death, Bupa told HDC the rest home had facilitated education sessions on topics including palliative care, emergency procedures, neurological assessment, wound care, medication management, and recognising and reporting changes in condition.
The nurse told HDC she had read further literature on sepsis in an attempt to understand where she may have overlooked the symptoms.