Woman died after poor care

AMY MAAS
Last updated 18:09 16/12/2013

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An Auckland nursing care facility for people with long-term illnesses has been criticised for multiple system failures after a woman in its care died after her bed sores became septic.

Departures in the care of the woman, known only as Ms A, received at St Joans Hospital in Mt Wellington, contributed to the development of a pressure ulcer which became septic and led to her death, a decision released by the Health and Disability Commissioner has found.

The 40-year-old had been admitted to the facility two years after a stroke left her paralysed on her left side. She also had urinary incontinence, seizure activity and cognitive disruption. The woman also received care and treatment for several health issues. These included neurological assessments related to seizure activity, behavioural and psychiatric assessments for low mood and dietitian input for weight management.

Five-and-a-half years after the woman was admitted, doctors found her pressure ulcer risk was high, however no preventive measures were taken. Four months after the assessment, the woman's condition began to deteriorate. She complained of nausea, did not want to eat or drink, and had a low mood. She then developed sacral pressure ulcers which did not heal and which became infected and necrotic.

The woman was then admitted to a public hospital with a high fever where doctors found she was also hypotensive and in renal failure. She died of sepsis two days later.

The Health and Safety Commissioner found that as well as multiple system failures in lack of care, there were also failings by the woman's GP, dietitian, nursing staff, the manager and the organisation. The clinical managers were criticised for not providing the woman with quality service and for failing to ensure appropriate care planning when she developed a pressure ulcer.

They also failed to ensure that she was adequately monitored while her health was deteriorating.
The recommendations made by the Health and Safety commissioner included that both nurses criticised in the report provide a written apology to Ms A's family. They were also told to review their practice in relation to risk assessment, care planning, monitoring, documentation and staff supervision.

Both nurses have fulfilled those recommendations.

St Joans Hospital was ordered to provide a written apology to the family, to review staff orientation, performance management and training in relation to the assessment and monitoring of clients.

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