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Death of rest home resident due to necrotising fasciitis (07HDC17744)

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(07HDC17744, 16 February 2009)

Rest Home ~ Registered nurse ~ Care manager ~ Fracture ~ Fall ~ Skin tear ~ Dementia ~ Pain assessment and management ~ Necrotising fasciitis ~ Rights 4(1), 4(2), 4(5)

The family of a 92-year-old woman complained about the care provided by a rest home, where the woman was resident for long-term care. She suffered a degree of dementia, needed a walker to mobilise, and had a high risk of falling. She had a number of falls at the rest home which resulted in skin tears.

A few months after admission, the woman's condition deteriorated, and she was reassessed as requiring hospital level care. However, before arrangements could be finalised to transfer her to a private hospital, she became unwell and developed pain in her left groin. An X-ray was taken, which showed no fracture. A few days later, the care staff noted that the woman's left leg was swollen and, the following day, she was transferred to a public hospital where she was found to have necrotising fasciitis. She died in hospital shortly afterwards.

It was held that care planning and needs assessment, documentation, pain assessment and management, bowel care, wound care documentation, pressure area management, and assessment and observation were not satisfactory. The inaction and failure to follow policies and meet contractual requirements by so many staff, over many months, was unacceptable. The woman was entitled to have services provided that complied with legal, professional, ethical and other relevant standards, including policies and contractual obligations concerning quality of care. The rest home failed to comply with its own policies and its contractual obligations in the DHB Aged Care Residential Agreement and to provide services with reasonable care and skill. Accordingly, the rest home breached Rights 4(1) and 4(2).

While the rest home was directly liable for the poor standard of care provided to the woman, the care manager bore a significant responsibility to ensure that a reasonable standard of care was provided by nurses and caregivers. Accordingly, by failing to ensure that the woman received an adequate standard of care, and for failing to facilitate co-ordinated care between herself and the medical practitioner, the care manager breached Rights 4(1) and 4(5).