Rest home death investigation: a daughter's quest for answers
Betty Bissett had two seizures before her morning shower at Tauranga's Aspen Lifecare, but an ambulance was only called nine hours later.
In the meantime, she was placed in a reclining chair and left in the lounge, vomiting occasionally.
The vomit not inhaled by Bissett dribbled down her neck and on to her clothes.
Twenty hours after her seizures - at 5am on April 25 - the 88 year old would die in Tauranga Hospital with her daughter Caroline Paterson by her side. Hospital staff would tell Aspen nurses the cause of death was aspirated pneumonia from the inhaled vomit. This is recorded in the last entry in Bissett's patient notes.
Former Aspen nurse Rebecca du Plessis said Bissett's ambulance was not called by the day-shift nurse, but by the night-shift nurse shortly after she arrived on duty.
"She took one look at her and said we'd better call the ambulance, but this should have been done immediately after the seizure. Aspen said she had a history of seizures, which was just nonsense. A seizure is always serious and should require hospitalisation, but this was not done for Betty. Instead, she was wheeled into the common room on a chair."
Aspen Lifecare Ltd director Paul Washer stands by the care his staff provided, saying seizures were "not uncommon" for Bissett. "She was being monitored by registered nurses and her observations were stable and within acceptable norms for the particular patient," he said in an emailed response to questions.
"We have checked and we can find no irregularity in the way that she was monitored or the information recorded.
"An ambulance was called as soon as a registered nurse became aware of the patient's deteriorating condition and ambulance staff and Tauranga hospital appropriately briefed. "
Du Plessis is risking her current and future employment by coming forward with the allegations. She said not doing so would be unethical.
Her complaint to the Nursing Council of New Zealand about Bissett's death is currently being investigated by its Professional Conduct Committee.
"You are not supposed to do any harm as a nurse," du Plessis said. "I think by not speaking out about this, we are all doing some harm."
Bissett was a well-liked resident at Aspen Lifecare, du Plessis said. She had come to live at the retirement home along with her husband Bob, who'd had a stroke. She was 88 but in relatively good physical condition for her age.
Bissett whiled away her days reading magazines and completing all the crossword puzzles. Her best days were when Caroline brought Bissett's grandson to visit.
Du Plessis said Bissett's death, the lack of care given to other patients and ongoing theft from residents were the reasons she resigned.
"I wanted to stick it out there, as I care for all the residents and I was worried about what would happen if I left," du Plessis said.
Du Plessis is not the only person breaking ranks. Former Aspen clinical nurse manager Tania Porter is also risking her own current and future employment by speaking out.
Porter had particular concerns about the patient notes regarding Bissett's final hours. "The notes show irregularities that just do not make sense," she said.
However, Washer says an investigation from the Bay of Plenty District Health Board could not substantiate any claims of wrongdoing in Bissett's case. "Subsequently, a Bay of Plenty DHB-commissioned audit also considered the allegations and, in their words, did not find evidence to uphold the allegations," he said.
Du Plessis and Porter said Bissett's patient notes tell the full story of what happened to Bissett and they cannot understand how an audit missed this.
The notes say at 6.40pm on April 23, the night nurse noted Bissett had good food and fluid intake. "No other concern."
The night nurse had kept a close eye on Bissett as she had been unwell and vomiting the previous week but she had recovered well.
Notes in the few days leading up to her death do not mention any illness and no antibiotics were prescribed.
On the morning of April 24, Bissett suffered the two seizures that would culminate in her death at Tauranga Hospital at 5am on April 25.
These seizures were not recorded in her notes until 5.20pm on April 24. No other entries or updates on her condition were recorded for the hours between the seizures and when Bissett was taken to hospital.
The only note during this time was written by the facilities manager, who was also a registered nurse, in retrospect for the morning's observations. The time they were written was 5.30pm, 10 minutes after the night nurse's note and while the night nurse was calling an ambulance for Bissett.
"Blood Pressure 130/78, Heart Rate 72 bpm and temperature 37.4 degrees," were the vital signs recorded hours after they were supposedly taken.
"Asked to see Betty at 0900 hours secondary to seizure," the notes say. "Betty had seizure when getting ready for a shower. She was on the shower chair and face went blank for a few seconds and eyes appeared to stare through you rather than looking at you. Second seizure once shower cancelled and she was dressed and back on bed. Able to squeeze my fingers. Able to follow commands."
"It seems to me these notes were written to cover something," Porter said. "If someone had had a seizure, why would no one check up on them and why would there be no notes recorded of this?"
This theory is backed by another employee at Aspen, who alleges the equipment used to measure such vital signs referred to in the notes could not have been used to make Bissett's observations. The healthcare assistant who stayed behind to sit with the dying patient confirms she had the machine and it was only returned to the nurses' station at 9.40am.
"I never even heard someone enter into Betty's room that morning and would have, as I was right next door," said the employee, who declined to be named.
Bissett's patient notes show the night nurse monitored Bissett at 6.40pm on April 23. Her entry at 5.20pm the next day - the next notes to be made on Bissett's file - about an hour after she came on duty, shows grave concern.
"Reported that Betty wasn't feeling good and had a couple of seizures," she wrote.
"When writer went to give Betty medications around 1630 hours, she was looking very pale and exhausted. Checked Betty's obs at 1700 hours. Blood pressure 110/70 O2 78 per cent and temperature 38.5. Pulse was 112."
Paracetamol and oxygen were given. "Betty said she is feeling terribly sick," the notes read.
The remaining notes by another nurse tell the sad end.
"1820 - Rang Mark Petersen [sic] for Carolyn Peterson [Caroline Paterson] to ring Aspen. Caroline rang and was informed at Betty's condition.
"2015 - Received a phone call from TPH (Tauranga Primary Hospital) regarding Betty. Explained Betty's daughter would visit tomorrow. TPH stated it would be good if they could attend tonight. Provided Carolyn's [sic] number."
"2250 - Rang TPH at 2235 for update. She is in ward 2B. Carolyn going to stay with Betty. Reviewed by GP and Betty is on Antibiotics. Going to see overnight if Betty responds to treatment or not.
"0315 - TPH RN stated Betty is responsive but very unwell.
"0745 - Received call from daughter that Betty passed away in the TPH around 0500 this morning. Chest infection/aspirate pneumonia due to vomiting yesterday. Carolyn came into Aspen to tell Bob and he took the news well."
The last line before the notes stop forever reads, "Carolyn said Betty went peacefully and without pain."
Paterson asked for a copy of Bissett's notes, but was declined. The person who held Bissett's power of attorney asked for a copy of the notes, but was also declined. Aspen management said the only person who could request the notes was the ailing Bob Bissett.
The person holding Bob's power of attorney then requested the notes. This request was also declined.
A copy of the notes was shown to Stuff and only published after Bissett's family gave permission.
The New Zealand Nursing Council verified complaints have been filed against the facilities manager and the Professional Conduct Committee was investigating. The organisation declined further comment.
Bissett's death certificate named cause of death as a Lower Respiratory Tract Infection which she must have had for at least four days. Frailty syndrome (old age) was also listed.
Du Plessis believes the last entry in the patient notes show the true cause of death. "She did not die from frailty syndrome," she said. "She died from aspiration pneumonia from not being looked after. She died within 24 hours. She didn't have a chest infection. We had all interacted with her. That yellow phlegm on her shirt was there because she had vomited a number of times."
The hospital said the death certificate read four days because the handover notes recorded that as the date Bissett first felt unwell.
Du Plessis also believes that if an ambulance had been called at the first seizure, the morning of April 24, Bissett would likely have survived.
"When old people get sick, they deteriorate very fast and it is harder for them to bounce back," she said. "You need to pick it up early. If you wait too long, it's usually too late."
While death is a part of life in respite care homes, du Plessis considers Aspen lost an unusual number of its 54-resident capacity in a short period of time.
"We lost 11 people in 12 days," she said. "Three in a 24-hour period. They were from things you shouldn't die from. Colds."
A non-medical contractor at Aspen also noted the high mortality rate and remember flagging this with management. "I said this seems very strange," the contractor, who declined to be named, said. "The manager just said it was just as high as other places and didn't seem to care."
The Bay of Plenty DHB contracted Health Share to conduct an "urgent issue-based audit" of Aspen on April 31. Aspen was informed of the audit ahead of time. Among the findings, the audit revealed a patient had suffered a drug overdose and there had been at least one other near miss. The audit also showed care plans were not updated or actioned as often as they should, $12,000 of residents' money was unaccounted for, and neurological assessments after falls were not completed on time, and the staff employment process was lacking, as references were often not checked.
Off-site doctors for Aspen were able to prescribe drugs for the registered nurses to administer. One such case occurred when a 101-year-old woman was put on a syringe driver for morphine with a very "loose" prescription of pain medication of 5-50mg/ml.
"Two registered nurses who set up the syringe driver and a third that was on overnight failed to see that the resident was in a coma ... a resident was identified in the complaint as being given an overdose of morphine," the audit read. The patient survived because it was caught by another source."
Washer said in response: "The audit does make a number of recommendations on improvements that should be made and I can confirm that they have been implemented. In our view, these constitute improvements to what were fundamentally sound systems and practices.
Talking specifically to audit points, Washer said the overdosed patient died nine months after the incident. "The recommendations to improve delivery of narcotic medications have been implemented. The audit also found staff misinformed the patient's family, saying the incident was a reaction to a drug and not a drug overdose."
"We regularly survey our residents who consistently rate our performance in terms of quality of service in the high 90 per cent," he said.
Systems and structures and robust procedures mean little for Paterson now. Her mum is gone and that feeling she had at her bedside that something seemed a little off was stirred up again as new information kept coming to light.
"I knew that speaking about this would be difficult," Paterson said, "but I feel we need to discuss this topic if we want to prevent others falling into the same fate my mother did.
"To those caregivers who spoke up and risked so much to take these issues to the media, thank you so very much."