Latest news with #HealthandDisabilityCommissioner
Otago Daily Times
14-07-2025
- Health
- Otago Daily Times
Care facility didn't report resident's sexualised behaviour
Warning: This story discusses sexual violence and suicidal ideation. The Health and Disability Commissioner has identified shortcomings at a disability care home, where sexual abuse, violence and self-harm occurred. Deputy Commissioner Rose Wall has found Spectrum Care, a major disability care provider, breached the rights of three residents at one of its homes. The complaints were lodged in 2021 by family members or guardians of the residents. One resident, referred to as Mr D, who was in his 20s at the time, had an intellectual disability and foetal alcohol spectrum disorder (FASD). The report said he had a history of repeated acts of violence, intimidatory and sexualised behaviour aimed at other residents, and a history of self-harm and suicide attempts. Mr D's father, referred to as Mr C in the report, said he was concerned someone was going to get badly hurt if Spectrum did not step in to safeguard all involved. He said despite complaints to Spectrum the situation was not addressed adequately, and Spectrum had not communicated adequately about incidents involving his son. For example, Mr C said that he was not told when Mr D attempted to commit suicide three times. Mr C does not hold a welfare guardian order for Mr D. The report said Mr D was quite independent and able to communicate his needs clearly, unless highly anxious, and had said he wanted to advocate for himself. A complaint was also made by the family of a man known in the report at Mr A. Mr A was in his 60s at the time, and non-verbal. He had contracted measles as a child and had been diagnosed with developmental delay and an intellectual disability. Mr A's family said the mix of different disabilities and ages in the facility was inappropriate and unsafe. They said Mr D had been physically and sexually violent toward Mr A and others in the facility. Mr A's family said they asked Spectrum to control the situation and safeguard Mr A from Mr D's behaviour, but Spectrum failed to do this. They said staff at the facility had not reported all the incidents, had failed to tell them about incidents, and had not considered any of the incidents urgent, including sexual assault. A third resident, Mr F was in his 20s at the time, and had an intellectual disability, foetal alcohol spectrum disorder and oppositional defiant disorder. Mr F's welfare guardian said that he was not getting the 24/7 care he was entitled to, and the guardian had not been told of serious incidents in a timely manner. This included when Mr F was moved to another Spectrum facility. Wall said in her report that Spectrum was in breach of the Code of Health and Disability Services Consumers' Rights. She said Spectrum did not have an "optimal mix of residents" at the facility, and following a serious incident in April 2021 should have considered relocation of residents a priority. She recommended Spectrum apologise to the complainants, develop a formal whānau communication strategy and a procedure for consumers who were independent, not under any formal orders and didn't want information shared with their family. Spectrum accepted the Deputy Commissioner's recommendations, and had made a number of changes. It said it would now classify each incident of sexualised behaviour as a serious incident, and would complete a serious incident investigation for each. It had also introduced a new feedback system, brought in a new incident management system, and increased training for staff. Where to get help: Need to Talk? Free call or text 1737 any time to speak to a trained counsellor, for any reason. Lifeline: 0800 543 354 or text HELP to 4357. Suicide Crisis Helpline: 0508 828 865 / 0508 TAUTOKO. This is a service for people who may be thinking about suicide, or those who are concerned about family or friends. Depression Helpline: 0800 111 757 or text 4202. Samaritans: 0800 726 666. Youthline: 0800 376 633 or text 234 or email talk@ What's Up: 0800 WHATSUP / 0800 9428 787. This is free counselling for 5 to 19-year-olds. Asian Family Services: 0800 862 342 or text 832. Languages spoken: Mandarin, Cantonese, Korean, Vietnamese, Thai, Japanese, Hindi, Gujarati, Marathi, and English. Rural Support Trust Helpline: 0800 787 254. Healthline: 0800 611 116. Rainbow Youth: (09) 376 4155. OUTLine: 0800 688 5463.
Otago Daily Times
09-07-2025
- Health
- Otago Daily Times
Woman found dead four hours after calling 111
A woman struggling to breathe early on Christmas Eve called for an ambulance, but died before one arrived more than four hours later. An ambulance crew arrived at Barbara Rose McGee's Auckland home around 7am and found her dead in her bed. It was the third unit dispatched to help McGee that morning in 2022, after the first two were diverted to higher-priority calls. A coroner found that the 67-year-old, who suffered from emphysema, died from a type of pneumonia known as acute bronchopneumonia, which caused inflammation to her airways and lungs. Two months earlier, a man lay dying in front of family and friends who tried in vain to save him during the 45 minutes it took for an ambulance to arrive. NZME reported in January this year that the Health and Disability Commissioner had received 166 complaints involving Hato Hone St John from July 1 in 2019 to 30 June 30 last year. They included two cases where people died because of delays in the arrival of ambulance crews. A coroner has again pointed to failures in the ambulance call-taker process. In her recent findings, Coroner Erin Woolley said that McGee's initial 111 call was incorrectly coded, and that standard procedure around welfare checks was not followed. Damian Tomic, St John's deputy chief executive of clinical services, told NZME it apologised unreservedly for what happened, and had extended condolences to McGee's whānau, whom the service had offered to meet. Call for help that arrived too late According to the findings, McGee experienced difficulty breathing early on Christmas Eve in 2022. Her son had visited the day before and made her comfortable after she messaged to say she had the "flu and a fever" and was "very weak and sleepy". Around 3am, McGee phoned 111 and asked for an ambulance. She had also tried to reach her son by text message to say she was going to the hospital and that she could not breathe. Her son woke to the messages at 6am and was told by police of his mother's death when he later arrived at her house. When McGee called the ambulance, she told the call taker she had been unwell for a while and was experiencing shortness of breath. The call was coded as an "orange" response, which meant it was considered serious, but not immediately life-threatening. An ambulance was sent about 15 minutes later but was then reassigned to attend a call coded as "an immediate life-threatening situation". At 4.20am, an emergency call handler phoned McGee to conduct a welfare check. Coroner Woolley said the notes from this call indicated there had been no change in her condition. A further welfare call was made at 5.30am, but McGee was unable to be reached. A second ambulance was sent an hour later, but that too was reassigned to a higher priority call. A third ambulance was sent to McGee's address just before 7am. It arrived 10 minutes later, but McGee was dead. Procedures 'not correctly followed' Coroner Woolley found that welfare calls should have been made every 30 minutes until emergency services arrived. When McGee could not be reached, further attempts should have been made to contact her, and if there was still no response, then a reassessment would have been required. "On this basis, it appears that in addition to Barbara's initial call being incorrectly coded, the standard operating procedure about welfare checks was also not correctly followed," the coroner said. St John investigated its response and found that the call handler had incorrectly recorded McGee's answer to a question about her breathing. The handler asked McGee if she had difficulty speaking between breaths, and recorded "no", but a review of the call found McGee could clearly be heard struggling to breathe. Coroner Woolley said the answer should have been recorded as "yes". "Had Barbara's answer been correctly recorded, her call would have been coded as a 'red' priority/immediately life-threatening situation, requiring the immediate dispatch of an ambulance." St John told the coroner that it would have provided further training to the relevant call taker; however, that person had resigned after what happened. One of the improvements the service identified was the possibility of creating a process to address the situation when no voice contact was established during a welfare call. It also proposed changes to the line of questioning and the terminology used for these call-backs, currently referred to as "welfare checks", to make them more safety-focused. Coroner Woolley recommended that St John ensure all call-takers were reminded of procedures around welfare checks, and that if contact could not be made, attempts must be made every five minutes and a reassessment done. St John told NZME it accepted the coroner's findings and recommendations. "Patient safety is a core priority, and we've made significant improvements to how welfare checks are conducted," Tomic said. They included more timely follow-ups and changes to the way checks were structured and phrased to ensure they were clear, consistent and safety-focused, he said. - By Tracy Neal Open Justice multimedia journalist of NZ Herald
Scoop
28-05-2025
- Health
- Scoop
Providers Named After Failing To Meet HDC Recommendations
Decisions 22HDC03019 and 23HDC01424 The Health and Disability Commissioner (HDC) has taken the unusual step of naming two providers who have not complied with recommendations made in decisions issued by the HDC. HDC promotes and protects the rights of people using health and disability services, as set out in the Code of Health and Disability Services Consumers' Rights (the Code). Two consumers (Mr A and Mrs B) complained to HDC about services they had received from Nicholas Stoneman and the New Zealand Disability Trust (NZDAT). Mr Stoneman was chairman of the NZDAT at the time. Mr A and Mrs B' complaints raised concerns about poor organizational processes, a lack of policies and procedures, Mr Stoneman and the NZDAT's exploitation and treatment of vulnerable consumers, and their poor engagement with the complaints process. HDC undertook an investigation. In October 2024, Mr Stoneman and NZDAT were found to have breached the Code and not provided Mr A and Mrs B with an appropriate standard of service. In her decision, HDC Deputy Commissioner, Rose Wall, recommended Mr Stoneman provide both complainants with a written apology and comply with a number of other recommendations. Despite repeated follow up from HDC, Mr Stoneman and NZDAT have not complied with any of the recommendations. "In failing to meet any of my recommendations, Mr Stoneman and NZDAT have failed to comply with their legal obligations under the Health and Disability Commissioner Act 1994. They have demonstrated a lack of commitment towards improving their practice. "In the circumstances, I consider Mr Stoneman and NZDAT pose a risk to other vulnerable consumers. I have therefore decided to re-issue the decision and name them." Ms Wall said anyone who had received substandard treatment from a practitioner should contact HDC if they wished to submit a complaint.
1News
26-05-2025
- Health
- 1News
'Left in chair covered in faeces' – widespread failures at resthome
There were widespread failures at a Geraldine resthome which did not properly care for three women, the Health and Disability Commissioner has found. The commissioner's 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-19 isolation. She later died, still in isolation. Mrs A complained about her lack of personal space for bathing, her lack of care and the dismissive attitude of staff and management at the facility, and her social isolation. ADVERTISEMENT The daughter of Mrs E said that when she was isolated during a Covid-19 outbreak, there was a lack of support with hydration, nourishment, and hygiene. The daughter of Mrs F raised issues with a lack of support for toileting and a poor call-bell response time. The commissioner found McKenzie Healthcare in breach of Rights and the Code of Health and Disability Services Consumers' Rights for all three women. No 'reasonable standard of care' The Health and Disability Commissioner 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". ADVERTISEMENT "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," Cooper said. "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." 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. 'Left in her chair or bed covered in faeces' 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 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". ADVERTISEMENT 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. 'Curled up in a soiled bed with matted hair' 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. ADVERTISEMENT "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 Health and Disability Commissioner 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. 'Poor staffing and a bad work culture' 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". ADVERTISEMENT 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 toldHealth and Disability Commissioner 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 Health and Disability Commissioner 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. Recommendations ADVERTISEMENT The commissioner recognised the resthome had made significant changes since 2022, and made a number of recommendations to McKenzie Healthcare, including: A written apology to the women and their families Complete education on communication with and about older people and their whānau, including strategies for ensuring that changes in resident needs are documented safely and communicated appropriately to minimise the risk of similar occurrences in the future Complete education on caring for people living with dementia mate wareware, including around person-first care, recognition of change or decline, use of the STOP and WATCH tool, and related responsibilities in care and communication An update on the changes made to improve its systems and processes, within an evaluated corrective action plan Discuss with the nursing team the importance of accurately recording all concerns raised by the family in the resident's clinical record Provide copies of certification of completion in relation to HDC's online modules for all current staff, within six months of the date of this report Complete an audit of all call-bell response times and provide a copy of the new policy Provide evidence of the standards of care it has developed for its caregivers and evidence of the training provided to caregivers, within 12 months of the date of this report Consider seeking support from South Canterbury ARC health experts to strengthen its clinical practice standards, to inform individualised assessment, planning, and delivery of safe resident care.
Scoop
22-05-2025
- Health
- Scoop
Record Investment In Health Delivery
Minister of Health The Government is again delivering record investment in healthcare, providing New Zealanders with better health services and ensuring hospitals and healthcare facilities are fit for the future, Health Minister Simeon Brown says. 'Budget 2025 provides a $7 billion increase in Vote Health operating funding over the forecast period. This includes the $1.37 billion per annum increase to Health New Zealand's baseline – bringing total health spending in 2025/26 to $32.7 billion,' Mr Brown says. 'Budget 2025 confirms our commitment from last year's Budget of a record investment in health over three budgets. That funding is already delivering results – more elective surgeries, GP appointments, and other critical healthcare services New Zealanders rely on. 'Other new initiatives include $91 million to increase prescription lengths and $447 million to support increased access to primary care. 'Budget 2025 also invests over $1 billion in new capital to deliver modern, fit-for-purpose infrastructure that meets the health needs of New Zealand's growing and ageing population. 'We're also making real progress on our health targets. Emergency department wait times are coming down, cancer patients are being seen faster, and childhood immunisation rates are improving. 'This year's Budget builds on that momentum, with targeted investments to strengthen frontline services and improve access to GP and specialist care across the country.' Advertisement - scroll to continue reading For patients, this funding will support Health New Zealand to deliver its plan for increased care for patients and will include: 21,000 additional planned care treatments (to an estimated 343,000 treatments) 31,000 additional cancer treatments to administer new funded medicines (to over 455,000 treatments) 22,000 additional people receiving inpatient care (to an estimated 984,000 people) 50,000 additional events in emergency departments (to a projected 1,411,000 events) 231,000 additional general practice encounters (to a projected 21,824,000 encounters) 119,000 additional bed nights in the residential aged care sector (to a projected 9,717,000 bed nights, excluding psychogeriatric bed nights). Specific Budget 2025 initiatives include: Increased access to urgent and after-hours care, helping to reduce pressure on emergency departments Expanding the primary care workforce, including training more doctors and nurses locally 24/7 access to digital primary care for online medical consultations, making it easier for people to get advice and prescriptions from their own homes Easier access to long-term prescriptions and broader prescribing rights across the health workforce Streamlined transfers from hospital to aged care, helping free up inpatient hospital beds and improve continuity of care Increased funding for the Health and Disability Commissioner to improve complaint resolution and care standards Support for a new multi-agency response to mental health distress calls Continued investment in hospital and facility upgrades across the country, ensuring clinical environments are safe, modern, and fit for purpose. 'We are delivering on our promise to put patients first. This additional investment of 7.4 per cent in total funding represents an increase of 6.2 per cent per capita, which will make a real difference to people's lives – ensuring timely, high-quality care for patients while supporting our frontline workforce who deliver that care every day. 'Budget 2025 reflects our commitment that all New Zealanders – no matter where they live – deserve a health system they can rely on that is focused on delivering for them, the patient,' Mr Brown says.
