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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
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).