Latest news with #CarolynCooper
RNZ News
26-05-2025
- Health
- RNZ News
'Left in her chair covered in faeces' - widespread failures at resthome
The resthome says it has worked to address the issues raised in the report. File photo Photo: There were widespread failures at a Geraldine resthome which did not properly care for three women, the Health and Disability Commissioner (HDC) has found. The HDC report followed three separate complaints about the standard of care the women received from McKenzie Healthcare Limited between 2020 and 2022. The resthome said it had worked to address the issues and improve quality and consistency. Known in the report as Mrs A, Mrs E and Mrs F, the report found the resthome left one of them covered in faeces and another in a soiled bed in Covid isolation. She later died while still in isolation. The commissioner found McKenzie Healthcare in breach of Rights and the Code of Health and Disability Services Consumers' Rights for all three women. The HDC found that between 2021 and 2022 there was a significant turnover of multiple staff at a frontline and management level, including five general managers. The current general manager stepped into the role despite having no previous knowledge of New Zealand's aged-care systems, and did not receive a formal orientation for the job. Aged Care Commissioner Carolyn Cooper said after carefully reviewing all the information she considered that "McKenzie Healthcare did not provide a reasonable standard of care for the three consumers". "I consider that the care provided in each case demonstrated a system-level failure. There was a consistent pattern of poor care for multiple consumers, and inadequate organisational systems to support staff in providing effective care. "In my opinion, this resulted from a lack of robust leadership, a lack of strategic direction, and poor clinical oversight. This had a cascading effect on healthcare delivery and resulted in a failure to provide appropriate care and assistance to McKenzie Healthcare staff and residents," said Cooper. Current clinical general manager Jo Fenton told RNZ in a statement the report had been taken on board. "We acknowledge and accept the findings of the Health and Disability Commissioner's report. Since then, we have been working diligently to address the issues raised and to improve the quality and consistency of our service delivery," she said. Mrs A was a 67-year-old woman with multiple comorbidities, including type two diabetes which required insulin, a stomach hernia, and a previous stroke. She was legally blind and had two stomas, and was also prone to recurrent urinary tract infections. Although a long-term care plan (LTCP) identified that Mrs A needed full assistance with hygiene and toileting, with her stoma bags to be checked and changed at least twice a week - she had several "blow outs" and was "left in her chair or bed covered in faeces". This led to her stoma becoming infected, and she was banned from using the shared toileting facilities - leaving her in "total isolation". The report also stated that Mrs A was left in her soiled clothes for extended periods, and the lack of help from staff led her to discharge herself from McKenzie Healthcare. The investigation found no evidence of a short-term care plan when Mrs A suffered gastroenteritis and was put in isolation, and no formal training for staff around infection control. It stated that "she was unable to be showered even after being soiled with faeces due to blow-out of the colostomy bag. She was made to wait until staff were available to shower her and clean up afterwards. This furthered her feelings of social isolation and emotional distress," the report said. The daughter of Mrs E complained about her care during a Covid-19 outbreak in 2022, and says she passed away after a long period of isolation when she received little attention and assistance. The 98-year-old was admitted to McKenzie Healthcare in 2020 for hospital-level care, and had a history of glaucoma, dementia with marked short-term memory loss, visual impairment, frailty, gluten intolerance, malignant melanoma, osteoarthritis, and hearing impairment. When she tested positive for Covid-19 in 2022, Mrs E was placed in isolation for 16 days and was still isolated when she died. The investigation found no reason for her extended isolation. "No rationale for this extended isolation was documented, and there is no evidence that an assessment was completed at the 7- or 10-day point to assess whether continuing isolation was necessary," said the commissioner. The resthome told the HDC that other than a low grade fever, Mrs E did not have any other Covid-19 symptoms. When her granddaughters visited her, they found Mrs E "lying curled up in a soiled bed with matted hair, and dry and scaly skin, and it appeared that she had not been moved for some time". The family said her dentures had not been fitted so she could not eat, there was no straw for her to drink fluids with, and she had been complaining of hunger. "When Mrs E's family challenged staff about their lack of attention to Mrs E, staff responded that it was difficult to continually don their PPE and therefore, frequent visits and checks had been avoided," the report stated. McKenzie Healthcare reviewed their care of Mrs E, and found trends of poor communication and documentation, no records of staff training on fluid and food recordings, no activities for Mrs E in isolation, no liaison with GPs and no end of life management was implemented. The third complaint was made by the daughter of Mrs F, who was concerned that staff at the resthome took too long to answer the call bell because of "poor staffing and a bad work culture". Mrs F was a 79-year-old woman who was transferred from McKenzie Village to McKenzie Healthcare for hospital-level care because of a decline in her health and ability to manage the activities of daily living. She had poor mobility and required full assistance with all personal care - including toileting and incontinence as she needed to urinate four to five times overnight. She also had chronic kidney disease, congestive heart failure and lethargy. Staff told HDC that Mrs F had a fluctuating mood, and she became tearful and screamed when left alone for more than 10 minutes. They said she became verbally aggressive towards healthcare assistants, and frequently complained about elder abuse. This made them anxious about attending Mrs F alone, which potentially delayed their response to the call-bell. Mrs F's daughter told the HDC that it took one to 1.5 hours for the call-bell to be answered, leading to "her dignity being taken away". The call-bell system is run remotely by a third party, and rest home residents are given a pager for the caregiver assigned to that room. After a family meeting about the delay, a registered nurse pager was given to Mrs F to use when call-bells were not answered. "No minutes were provided for this meeting, and there is no evidence of the corrective action plans or investigations undertaken into the complaint," the report said. McKenzie Healthcare acknowledged that extended call-bell response times may have been due to staff attending to other residents. It apologised for this and stated that there was no excuse for not checking on Mrs F. The investigation also found problems with the care of Mrs F's incontinence. "It appears from the documentation that information was recorded inconsistently on the forms. Some days recorded only one episode of urine being passed, while on other days there were no entries," the report said. The commissioner recognised the resthome had made significant changes since 2022, and made a number of recommendations to McKenzie Healthcare. The recommendations include: Sign up for Ngā Pitopito Kōrero, a daily newsletter curated by our editors and delivered straight to your inbox every weekday.
RNZ News
13-05-2025
- Health
- RNZ News
Surgery error: Woman operated on for gallbladder already removed
By Al Williams, Open Justice reporter of Palmerston North Hospital. Photo: RNZ / Jimmy Ellingham An 80-year-old woman underwent surgery for the removal of her gallbladder, only for the surgeon to discover it had already been removed several years earlier. Deputy Health and Disability Commissioner Carolyn Cooper has highlighted failures by staff in reviewing the woman's medical history and told Health MidCentral to apologise. According to the decision, which was released on Monday, the woman was admitted to Palmerston North Hospital with abdominal pains in 2020. It was recorded that she did not have a history of gallstones, and there was no mention that a cholecystectomy (surgical removal of the gallbladder) had occurred in 2005. During her admission, an ultrasound identified the presence of at least one gallstone and the gallbladder was noted to be "not well distended" with a "thickened wall". She was admitted to the ICU ward a couple of days later because of respiratory distress and severe pancreatitis. Again, her history was noted, but there was no mention of surgical removal of the gallbladder. A CT scan of her abdomen and pelvis that day noted the gallbladder was "shrunken" with at least one gallstone seen. Cooper said in her decision that the woman had three sets of clinical records. The first set was sent to the ICU ward the day after the CT scan and included reference to the cholecystectomy in 2005. A consultant general and gastrointestinal surgeon, referred to as Dr C, told the deputy commissioner that the medical history was obtained both from A and from her electronic clinical records, which recorded hypertension, ischaemic heart disease, and a hemicolectomy in 2005. A hemicolectomy is a surgical procedure where part of the colon is removed. Dr C said that, based on the ultrasound and CT scan and with no known history of gallbladder or gallstone surgery, he assumed that the cause of her severe pancreatitis was gallstones. The woman's daughter, referred to as Ms B, told the commissioner that her mother's records should have been looked at more closely, given her understanding that a cholecystectomy is common during bowel surgery. Deputy Health and Disability Commissioner Carolyn Cooper Photo: Supplied / Office of the Health and Disability Commissioner The woman's condition improved and she was put on a waiting list for laparoscopic cholecystectomy surgery, the surgical removal of the gallbladder using a minimally invasive approach, following a consultation with Dr C. All three sets of her medical records were provided to the hospital's pre-admission clinic three months later and the woman attended a pre-anaesthetic clinic, where her previous hemicolectomy surgery was recorded. But, again there was no record of the cholecystectomy. The consultant general surgeon performed the surgery about a month later. He said the woman had had a thorough history taken and there was no record of the cholecystectomy. He said that after commencing the laparoscopy it became apparent that a cholecystectomy had been performed previously and the surgery was abandoned. He searched the electronic system, which showed no previous documentation of a cholecystectomy. However, the hard-copy notes recorded that a hemicolectomy and a cholecystectomy had been performed at the same time. Dr C said the information had not been made available to him by the woman or by the hospital booking team. He said electronic records at Health NZ MidCentral had been in use since about 2010 and that there were few, if any, electronic clinical records available prior to that time. One of the woman's first electronic clinical records was a letter dated February 2013 following a clinic consultation by the surgeon who had undertaken the hemicolectomy in 2005, and the letter made no mention of the gallbladder removal that occurred at the same time, he said. He said it was not routine practice to review clinical records of patients on a waiting list in the time interval between placement on a waiting list and the surgery date unless there was a clinical problem, which was not the case. The electronic records, digital images, and imaging reports did not highlight the previous gallbladder removal, he said. Dr C said that hard-copy clinical records were often stored in several sets or volumes, which may or may not be available at the time. Older volumes were frequently stored off site and often it was the latest records that were made available. File photo. Health NZ apologised and is implementing measures to ensure a comprehensive review of electronic and hard-copy records. Photo: RNZ / Nate McKinnon Health NZ told the commissioner that a formal incident report was completed following the abandoned surgery and that a review was undertaken by the clinical lead for surgery. Following the woman's discharge, her daughter told the deputy commissioner that a Palmerston North Hospital staffer contacted her brother. The staffer outlined several inaccurate details about the incident and their mother's medical history, including that the scans were misinterpreted by a radiologist; her clinical notes did not mention the gallbladder removal in 2007 and that she had not been admitted to Palmerston North Hospital previously prior to her admission. Health NZ told the Deputy Commissioner that it was unable to identify the staff member who made contact with the woman's son, and it apologised for the inaccurate information provided. A subsequent review found that the paper clinical files with documentation of the gallbladder was contained in one of the clinical files, which was available for staff to review in the intensive care unit and available to the surgeon and the preoperative clinic. Records in the electronic clinical portal went back only to 2012 and the hard-copy clinical records prior were not captured in the clinical portal, reviewed by the anaesthetist only during the abandoned surgery. Hard-copy documentation of the gallbladder surgery was not reviewed by the surgeon prior to the surgery, nor at the preoperative clinic. The surgeon and anaesthetist had relied on the findings of scans performed prior to surgery. It was later recommended staff take all steps to ensure that both electronic and hard-copy files are reviewed sufficiently to enable informed decision-making; staff be educated on policy and procedure for open disclosure and how to record clinical incidents on software, and that phone calls to patients be recorded on a telephone consult form and filed in clinical records. Health NZ told Cooper that it unreservedly apologises to the woman and her family for the care she received. Cooper said multiple staff members had failed to review the hard-copy clinical notes adequately. "I consider that this case highlights the importance of significant details of a patient's clinical history such as previous surgeries being readily available and visible to treating clinicians. "I note that Health NZ told the Health and Disability Commissioner that it is now working through the implementation of scanning hard-copy clinical files into the electronic clinical portal, and I consider this to be an appropriate course of action to minimise the possibility of a recurrence of such an event." Cooper recommended Health MidCentral prepare and present an anonymised case study based on the events for the wider education of medical staff at Palmerston North Hospital and provide an update to the commissioner on the implementation of scanning hard-copy clinical files into the electronic patient clinical portal within three months of the decision. Cooper recommended Health Mid Central also provide an apology to the woman and her family. * This story originally appeared in the New Zealand Herald].
Yahoo
04-03-2025
- Yahoo
One dead, another critically injured in wrong-way crash outside of Morganton: NCSHP
BURKE COUNTY, N.C. () — One person lost their life and another is critically injured after wrong way crash just outside of Morganton, according to North Carolina State Highway Patrol. Around 9:30 p.m. on Monday, March 3, troopers responded to a crash on Interstate 40 westbound near South Sterling Street (NC-18). Investigators believe a 2016 Hyundai Sonata was driving the wrong way on I-40 and crashed into a 2022 Ford Mustang. Catawba College strives for a distinction shared by the world's top music schools The driver of the Sonata, 76-year-old Carolyn Cooper of Morganton, died at the site of the crash. The driver of the Mustang, 23-year-old Landon Keith Norris of Newton, was taken by a medical helicopter to Atrium Health Carolinas Medical Center in Charlotte for critical injuries. Troopers say speed and impairment were not to blame for the crash. No charges will be filed. I-40 was closed for about three hours during the on-scene investigation. Copyright 2025 Nexstar Media, Inc. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed.
