Director of Proceedings v The Ultimate Care Group Limited

Director of Proceedings v The Ultimate Care Group Limited [2022] NZHRRT 17 (8 April 2022)

The Director filed proceedings by consent against The Ultimate Care Group Limited (“Ultimate Care”) in the Human Rights Review Tribunal (“the Tribunal”), regarding the care provided to a man while he was a resident at Ultimate Care Karadean Court (“Karadean Court”).

The man, 87 years of age at the time of these events, had been a resident at Karadean Court since 2009. He had a number of health conditions, including a history of heart attack, atrial fibrillation, Type II diabetes, hypertension, stroke, hypothyroidism, ischaemic heart disease, and vascular dementia. While the man was a resident at Karadean Court, staff failed to provide healthcare services to him with reasonable care or skill. The failures in care included the following:

  • Ultimate Care’s Diabetes Policy did not outline the required frequency of blood glucose level testing. The regularity at which staff took the man’s blood glucose levels was inadequate with only four occasions recorded between 12 August 2015 and 29 April 2016. Throughout July and August 2016, when the man experienced dehydration, diarrhoea, and infection associated with an outbreak of norovirus at Karadean Court, staff did not increase monitoring of the man’s blood glucose levels. On 9 July 2016 and 15 August 2016, when the man’s blood glucose level was recorded at a level higher than the recommended range in his resident lifestyle plan, the man’s elevated reading was not escalated to a medical practitioner, and follow-up blood glucose readings were not taken;
  • The man’s resident lifestyle plan recorded that he was to be reviewed by a podiatrist if required, owing to his Type II diabetes. On one occasion, the man was not referred to a podiatrist when a review was recommended, and on a second occasion, a review did not take place until one month after it was recommended. A further review did not take place because the man did not attend, with no reason recorded for his non-attendance;
  • In July 2016, after being transferred back to Karadean Court after two days in hospital for a heart attack, the man was prescribed a low dose of metoprolol. The next morning, staff failed to administer the metoprolol to the man, and later that day he began to experience chest pains. Subsequently, the dose was provided after consultation with a rural nurse and a GP. Ultimate Care acknowledged that if the man had not had chest pains, it was most likely that the metoprolol dose would have been missed;
  • In October 2015, a Norton scale risk assessment (“Norton assessment”) of the man indicated that he was at medium risk of developing pressure sores. Between October 2015 and August 2016, further Norton assessments were undertaken. The man’s assessment remained unchanged despite deficits in his physical and mental condition, activity, mobility, and incontinence being recorded in his clinical notes and care plans;
  • In August 2016, the man developed a sacral pressure wound (identified on 13 August) and a pressure injury on his right foot (identified on 14 August). On 21 August 2016, when the man was admitted to Christchurch Hospital, his sacral pressure injury was described as “huge” and in need of specialist wound care for surgical debridement. The man’s Norton assessments, soft tissue care plans, and progress notes failed to reflect the serious nature of the wounds accurately;
  • On multiple occasions during January and February 2016, the man reported being in pain in relation to redness on his groin and scrotum; however, there was no indication that the man was offered or provided any pain relief;
  • In August 2016, the man became unwell with symptoms of norovirus. The man’s records during this time show that there was a gap in managing his symptoms, including the failure of staff to ensure that adequate fluid balance was maintained and that regular blood glucose observations were completed;
  • Reviews of the man’s continence assessment between August 2015 and August 2016 failed to recognise the decrease in the man’s continence; and
  • Between February 2016 and August 2016, there were several occasions when the man’s health issues were not escalated to a GP, when this should have occurred.

On 21 August 2016, the man was diagnosed with a suspected parotid gland infection and prescribed antibiotics. That evening, after two unsuccessful attempts to administer the man oral antibiotics, he was transferred to Christchurch Hospital. A registered nurse at Karadean Court prepared a Transfer Referral Report, which accompanied the man to hospital. This report failed to record factors that were highly relevant to the man’s health status and nursing care on transfer to the hospital. Subsequently, the man was diagnosed with parotitis and sepsis. When he was transferred to a ward, it was noted that he had “large pressure sores over his sacrum, [and] necrotic tissue”. On 24 August 2016, the man died in Christchurch Hospital as a result of septicaemia and facial cellulitis.

Ultimate Care accepted that there were deficiencies in the care that its staff provided to the man, and that it had ultimate responsibility for that care. Ultimate Care further accepted that it failed in that responsibility and, in doing so, breached Right 4(1) of the Code. The Tribunal was satisfied that Ultimate Care failed to provide services to the man with reasonable care and skill, and issued a declaration that Ultimate Care had breached Right 4(1) of the Code.

The Tribunal’s full decision can be found at: