Forward planning and vigilance in medication management vital to ensure continuity and quality of care of older people

This case highlights the importance of accurate forward planning by providers for the admission of older people to care homes, and the need for vigilance to ensure that they receive their medications in a timely manner.

Older people are significant users of high-risk medications, and they are particularly vulnerable in situations where the transfer of important information relating to medication is vital. Critical thinking, good communication, and the use of initiative by healthcare professionals is essential to ensure the continuity and quality of care of older people as they transition through the health system.

An elderly woman was admitted to a care home. Following her admission, the woman did not receive her regular medications, most notably insulin, and she died less than 24 hours after her arrival at the care home.

Ngā Paerewa, the Health and Disability Service Standards, require organisations to ensure that consumers receive medicines in a safe and timely manner that complies with current legislative requirements and safe practice guidelines. 

The provider had policies in place to manage medication for new admissions to enable continuity of life-saving medications. The woman’s admission assessment detailed that she was taking warfarin and insulin, so nursing staff were aware that the woman required potentially life-saving medication and regular monitoring.

However, despite that notice, and having policies and procedures to manage the situation, the woman did not receive a prescription or verbal order for life-saving medications and, tragically, did not receive medication that could have managed her blood-sugar levels and ultimately may have prevented her death.


Overall, the care provided to the woman fell short of acceptable standards in a number of areas in a time frame of less than 24 hours. At least three of the four nurses involved in the woman’s care failed to fulfil their clinical responsibilities and adhere to policies and procedures. Policies must always be considered when planning and delivering care, as they are an integral part of nursing practice and responsibilities.

The provider was found to be in breach of Right 4(1) of the Code of Health and Disability Services Consumers’ Rights (the Code) for failing to provide services with reasonable care and skill.

The Deputy Commissioner also found two registered nurses in breach of Right 4(1) of the Code, and made adverse comment about the care provided by two further registered nurses.


The Deputy Commissioner recommended that the care home:

  • Review its insulin administration policy to include guidance for staff when blood sugar levels are outside the usual parameters;
  • Review the process of escalating GP contact attempts in situations where urgent medical review is requested;
  • Introduce a GP follow-up deadline and consider adding a reference section to the online note system for charting by GPs at admission or for pharmacy use in the event that a GP cannot be contacted; and
  • Review its process for asking the local medical centre to chart residents’ medications.

The Deputy Commissioner also recommended that the provider and the four nurses each write an apology to the consumer’s family, and familiarise themselves with the Ministry of Health publication “Medicines care guides for residential aged care” (2011).

The Deputy Commissioner further recommended that the Nursing Council of New Zealand consider whether a review of two of the nurses’ competence is warranted.

Read the full decision here.