The woman’s daughter complained to the commissioner following several complaints to Golden Pond. Her complaints included that Golden Pond staff would speak to her mother disrespectfully and delay or refuse to take her to the toilet.
Her complaint included that staff didn’t accommodate her mother’s hearing and speech problems, ignored her requests for help, failed to recognise she had a urinary tract infection and were slow to react when she had a fall.
Aged Care Commissioner Carolyn Cooper said in the report she found Golden Pond failed to provide services in a manner that treated the woman with respect, a breach of the Code of Health and Disability Services Consumers’ Rights.
Cooper, however, acknowledged the home and hospital had changed many of its practices since the investigation.
The report detailed Golden Pond’s apology letter, which said it was sorry for the way the woman was treated and the lack of communication and accountability.
The woman was in her 70s and received hospital-level care since her admission in May 2019.
She had a history of depression and limited vision and had been diagnosed with progressive supranuclear palsy, a complex, chronic neurological condition that affects speech, swallowing, eye movements and mobility.
Cameras were installed for security purposes and for the woman’s daughter to check if her mother had any falls.
The woman’s daughter became concerned about the care her mother was receiving based on events captured in 23 videos that were supplied to the commission as evidence.
She was frequently asking to use the toilet and staff became frustrated. They failed to recognise she had a urinary tract infection.
On the morning of her fall, she was left on the ground for 40 minutes before being found.
Golden Pond acknowledged there needed to be accountability for the failings in its care, but emphasised in its response to the commission that five years had passed and none of the staff members involved worked at Golden Pond anymore.
Cooper’s report said three of the videos were particularly concerning, including one where a carer was arguing with the woman while she was on the toilet.
“In my view, this incident demonstrates an appalling disregard for [the woman’s] dignity.”
In another video, the woman pleaded with staff to use the toilet but was told she should have gone earlier and that her incontinence pad would be sufficient.
“In my opinion, these repeated instances of demeaning conduct by several staff members, particularly in circumstances involving [the woman’s] toileting when she was entirely reliant on staff for her cares, amount to a failure to provide services in a manner that respected [her] dignity.”
Cooper’s report concluded there was evidence of a “concerning pattern of demeaning and disrespectful treatment” involving six staff members, including two nurses.
“While there is individual accountability for these actions, in my view, the continued widespread and repeated actions by staff at Golden Pond reflect a culture of disrespect and disregard for the dignity of those under Golden Pond’s care, for which, ultimately, I hold Golden Pond responsible.”
Cooper said Golden Pond had been aware of the woman’s daughter’s concerns since at least January 2020, and some action was taken.
“However, I consider that the continued inappropriate conduct of staff, over a period of months, indicates a failure by Golden Pond to manage, improve and monitor the situation adequately.”
She noted Golden Pond acknowledged in its response that it was too slow to pick up on the stress staff were under and put in strategies to deal with the woman’s behaviour.
A 2025 Golden Pond audit was complimentary of the service, and Cooper said in the report she commended Golden Pond on the “significant improvements” it had made since the complaint.
However, she still made the recommendation that Golden Pond provide evidence of its most recent staff training and education on elder abuse, respectful communication and conduct, and managing stress and challenging resident behaviours.
It had to provide evidence of that training to the commissioner within six months.
Kelly Makiha is a senior journalist who has reported for the Rotorua Daily Post for more than 25 years, covering mainly police, court, human interest and social issues.
