Latest news with #RoseWall
RNZ News
14-07-2025
- Health
- RNZ News
Spectrum Care didn't report or investigate disabled resident's sexualised behaviour
Deputy Health and Disability Commissioner Rose Wall. Photo: LANCE LAWSON / SUPPLIED 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 fetal 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, fetal 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. Sign up for Ngā Pitopito Kōrero , a daily newsletter curated by our editors and delivered straight to your inbox every weekday.
RNZ News
23-06-2025
- Health
- RNZ News
Woman lay dead more than two days in supported accommodation
Photo: 123RF A woman with an intellectual disability living in supported accommodation lay dead for more than two days before staff found her, an investigation by the Health and Disability Commission (HDC) has found. In a just-released decision, Deputy Health and Disability Commissioner Rose Wall said Spectrum Care Limited breached the woman's rights by failing to ensure she was taking her anti-epilepsy medication or carry out adequate checks on her well-being. A post-mortem examination found the woman in her 30s, who died in early 2021, had not been taking her medication as prescribed. The report noted the woman (Ms A), who had suffered a traumatic brain injury as a toddler, was "determined to live independently" and often refused help. "Ms A shared Spectrum support workers with the person living in the flat next to hers, and she was able to be supported 24/7. However, mostly the support she received was at her own request." Unless she asked for help, she was usually checked once a day - "or not at all if staff did not want to anger/wake her". She had a long history of threatening and physically aggressive behaviour towards staff and police, but over the years, Spectrum had given her support with "anger management" and trained caregivers in behaviour support strategies. Wall said Spectrum "should be commended" for supporting Ms A to live independently, but it failed to adequately mitigate the risks. She had her medication for epilepsy and diabetes in blister packs, at her request. "Staff were supposed to remind her daily to take her medication, and if she was in a 'good mood' she would take them. "In 2021 there are three recorded instances when A refused to take her medications. Spectrum noted that if A was angry, she would refuse and sometimes throw the medications over the fence or onto the roof, and sometimes she would hide the blister pack so that staff could not check it." The caregiver who delivered her evening meal said she could still hear music playing from Ms A's apartment the next morning, "which made her think that A must be in a good mood, although she did not see A all day". A second caregiver, who came on duty at 3pm, went to ask Ms A what she would like for dinner, but saw she was in bed with music playing. He assumed that was sleeping "and did not want to wake her as this could trigger aggressive behaviour". He went to her flat again the next day at 11am and saw she was still lying in the same position. He entered the flat, called her name, and shook her body but she could not be roused. An independent investigation commissioned by Spectrum after her death found Ms A had been assessed as needing 24/7 support with day-to-day needs. In practice, this occurred on a once-a-day basis only, unless Ms A requested additional support or not at all if staff did not want to wake/anger her. Sean Stowers, Spectrum Care chief executive officer. Photo: RNZ / Cole Eastham-Farrelly "It was established that A had not been seen face-to-face by staff for more than one day." Ms A operated "in a high-trust system and he was known to occasionally break that trust". "This inevitably put her at risk, and there were insufficient checks and balances in the system to mitigate those risks. [Ms A's] policy of only allowing staff into her space when it suited her was also a risk. While it honoured her independence, it also prevented staff from monitoring her welfare and compromised their duty of care. "Staff trusted her to take her medicine, but there was no way to check that she had taken it at the right time. When she died, which was probably on the night of [Day1] or in the early morning of [Day 2], it became clear that she had not taken any of her prescribed medication [for the last few days]. This put her at risk and staff had no way of knowing she was at risk." Spectrum has since introduced a 'Self-Administration of Medicine Agreement' outlining the conditions for clients who control their own medication. Rose Wall. Photo: Supplied / HDC An expert adviser to the HDC, John Taylor, said a once-a-day check-in for someone with "very high support" needs was a severe departure from both the expected standard of care and the contract. "It is concerning that it took such a tragic event for Spectrum to develop and implement a new SOP [standard operating procedure] outlining that wellbeing checks of residential consumers should occur at least thrice daily." Regarding the lax oversight of Ms A's medication, Taylor said this was "a severe departure from the expected standard of care". Allowing people the "dignity of risk" meant respecting a person's autonomy and self-determination to make his or her own choices, but also providing appropriate safeguards, information and strategies to "minimise the risk of harm", he said. "To be clear, there is no 'dignity' for a person if they are left to face the consequences of risks they could not foresee, manage or understand." Wall said Spectrum had accepted the finding of "an organisational breach", and had itself identified "service-level failings". She directed the provider to apologise to Ms A's mother and family for the issues identified in the report, and revise its operating procedures to include alternative ways of doing wellbeing checks and medication reminders. Sign up for Ngā Pitopito Kōrero, a daily newsletter curated by our editors and delivered straight to your inbox every weekday.
RNZ News
16-06-2025
- RNZ News
Disabililty support workers failed to follow policy in not physically checking on resident who went missing
Commissioner Rose Wall was critical of the fact that three support workers failed to follow policy. Photo: LANCE LAWSON / SUPPLIED A disability support service has installed alarms on all its doors after a resident who went missing on her birthday was found more than a day later, cold and naked, less than a kilometre away from the facility. The 32-year-old woman, who had an intellectual disability, was seen on CCTV footage wandering neighbouring properties in the early hours one night in 2020, however her disappearance didn't raise an alarm for another six hours. The support service was found to have failed in its care to the woman, after the woman's sister, known as Ms A, made a complaint to the Health and Disability Commission (HDC). In her decision - which was broadly accepted by the support service - Commissioner Rose Wall said the support service breached its own policies and she was also critical of the facility's communication with Ms A, during and after her sister, was in its care. The woman, known as Ms B, who had an intellectual disability and has since died, was known to exhibit challenging behaviours and had a complex medical history, Wall said. The facility where she lived was staffed 24 hours a day, seven days a week, with two support workers rostered on during the day, and one for a "sleepover shift" at night from 10pm til 6am. Support workers were expected to keep Ms B in their "line of sight" while she was awake and de-escalate if she was displaying heightened behaviours. On the eve of her birthday, Ms B was excited and awake - she was expecting a letter and planned to go for a birthday lunch, Wall said. An incident report earlier that day noted she was "'shouting", "[raising] her voice", "using rude language", and "making loud noise". "Medication was administered and staff instructed Ms B to '[calm] down and rest in her room'." Later, shortly before midnight, the sleepover support worker found Ms B awake and distressed, gave her medication and told her to go to bed. The support service told police that a check at 2am, found Ms B asleep in her bed. However, Wall said this was contradicted by CCTV footage that showed Ms B on neighbouring properties 400m away from the facility between 1.30am and 2.20am. In its own investigation the support service found that Ms B left the facility to check the letterbox - part of her normal routine - but became disoriented. The precise time she left couldn't be determined. Wall said at 6am the sleepover support worker completed a handover, but didn't physically check on Ms B and neither did the two incoming day workers. "The support service stated that this lapse in process was because staff had noted Ms B's agitation over the night ... and they wanted to allow Ms B to sleep in without disturbance." Wall was critical of the fact that three support workers failed to follow the policy, which she said was clear and particularly important given Ms B's agitation the night before. She said the failure amounted to a breach of the Health and Disability Code's standard of care and meant the alarm that Ms B was missing wasn't raised until a visual check at 8.30am. Her disappearance was reported to police about 45 minutes later and to Ms B's family shortly before 10am. Six additional staff deployed to help find her, in an extensive search undertaken by police and Search and Rescue teams. Ms B was found the next day at 1.15pm about 800m (an 11-minute walk) from the residence, Wall said. "Without any clothes, and she had a low body temperature, 'but otherwise [she was] OK'. Ms B was taken to hospital for treatment and observation." In her decision, Wall noted that as soon as Ms B was reported missing, the incident was escalated and managed promptly, however she was critical of the quality of incident reporting. Wall was also critical of the information provided to Ms A about assault allegations against Ms B and the adequacy of the documentation provided to Ms A when Ms B went to live with her following the incident. She said the support service had since enforced handover expectations for staff, increased the number of staffing on each shift, including the night shift, and placed alarms on its facility doors which were activated if anyone leaves the house. Wall acknowledged the improvements and also recommended the support service provide a written apology to Ms A and further training to staff around incident reporting, their roles and responsibilities, and documentation standards. Sign up for Ngā Pitopito Kōrero , a daily newsletter curated by our editors and delivered straight to your inbox every weekday.
