Family point finger at Brackenridge
The sister of an intellectually disabled man who died under Brackenridge care says an independent review into his death proves it could have been avoided.
The deaths of three residents at Christchurch's Brackenridge Estate in mid-2013 led to the public resignation of the facility's sole GP and a Ministry of Health audit that identified failings by management.
Dr Peter Wilkinson quit in September, citing fears for staff and resident safety and three deaths that he believes could have been prevented with better care and training.
Brackenridge commissioned an independent review into the deaths of the three residents.
The review was completed in December and after repeated requests from The Press, Brackenridge chairwoman Jane Cartwright recently released a summary of its findings. Key concerns identified a lack of accountability and visible leadership, issues with accessing health services, delayed response to incidents and inconsistent implementation of policy.
The review concluded care of the residents "could be considered adequate within the Brackenridge care framework", the summary said.
Cartwright said the full report would not be released due to "personal details".
However, The Press obtained a full copy of the review and spoke to family members who claim it proved their loved ones were "let down by Brackenridge".
Resident Mark Taylor, 56, died in August and his sister, Cec Anderson, believes his death "could have been avoided". She acknowledged Taylor was a high-needs resident with behaviour issues but said "the care just preceding his death was inadequate and helped contribute to his passing".
Anderson said some of the Brackenridge caregivers were "absolutely awesome", but there were others who were inexperienced and did not know how to handle or care for her brother.
"I don't think it was the carers' fault; the Brackenridge system was what let him down," she said.
The review detailed what happened before Taylor's death and raised several concerns about his care, including inadequate documents, lack of senior leadership, delayed investigation of incidents and the lack of appropriate involvement of behaviour support co-ordinators.
On July 26, medical records show Taylor was unsettled with "volatile" behaviour. Over the next two days he was agitated with "coughing, runny nose".
He was given medication for three consecutive days.
On July 29, an incident form said his behaviour was assaultive, with one staff member reporting that he "smashed" a dining room chair.
On July 31, he was again unsettled, with a runny nose and "above eye bruising". The next day he was "attacking often", sounded congested and would not allow Wilkinson near him to be assessed.
The following evening he was taken to hospital.
Taylor died on August 4.
"While areas of concern requiring attention are noted, the reviewers did not feel able to conclude that these inadequacies directly contributed to Mark's death," the report read.
The review also raised concerns about Brackenridge's model of care, which did not focus enough on the physical health problems many intellectually disabled people faced.
It recommended the facility do a stock-take of all roles to ensure staff were aware of their responsibilities, to review its policies for accessing health services, to review its internal audit programme and to start weekly onsite meetings with senior management.
Several changes and improvements have already been implemented at Brackenridge since the ministry audit and more initiatives are under way to improve care, Cartwright said.
Brackenridge is an intellectually disabled facility that provides full-time care to 65 residents at its gated Templeton community and residents at 18 community houses across Canterbury.
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