Investigation: escalation of care for rest-home resident with cardiac symptoms

A woman in her late eighties was a rest-home resident and had a medical history that included coronary heart disease and COPD (a lung disease).

The woman began to experience pain in her shoulder and breast. Early the next morning, the caregiver became concerned and called the on-call registered nurse. The nurse instructed the caregiver to record the woman’s blood pressure every hour and to call back if her condition deteriorated.

The nurse and the caregivers discussed the woman’s condition by telephone on two further occasions, but the nurse did not assess the woman in person.

Later that morning, the nurse became concerned about the woman’s blood pressure and instructed a caregiver to call a GP. However, a miscommunication between the rest home and the contracted and locum GPs meant that no GP attended the woman. During the afternoon, the nurse did not attend the woman to assess her, or call the rest home to monitor her condition.

That afternoon, the woman’s son called an ambulance because the rest home had not done so. Subsequently, the nurse telephoned the woman’s son and expressed her displeasure that he had called an ambulance.

The woman’s son was concerned that an elderly woman with known heart problems had to wait for 14 hours for medical help. He stated: “[Rest-home owners] have a duty of care to those who we trust with our elderly, and those in need.”


Deputy Health and Disability Commissioner Rose Wall found both the nurse and the rest home in breach of Right 4(1) of the Code. She considered that the instructions that the nurse gave to the caregiver were poor, and that the nurse did not provide medical intervention or arrange for it to be provided when it was required. When she became concerned about the woman’s condition, the nurse did not conduct a face-to-face assessment of the woman. The nurse did not check whether the GP had arrived; and her communication with the woman’s son was inappropriate.

The Deputy Commissioner also found that the rest home’s procedure for obtaining GP assistance was inadequate; the nurse’s workload and performance were not monitored effectively; the caregivers did not recognise the seriousness of the woman’s condition, and failed to take steps to obtain urgent medical care; and the Emergency Policy was out of date.


The Deputy Commissioner recommended that the nurse attend training in cardiac management, communication with family members, and the responsibilities of a sole registered nurse at an aged care facility.

The Deputy Commissioner noted that in response to HDC’s recommendations, the rest home made a number of changes, including developing a plan for professional supervision for the nurse, providing training to caregivers, and updating the “When to Call 111” poster. The rest home, in conjunction with the nurse, provided HDC with an apology to the woman’s family.

The Deputy Commissioner also recommended that the rest home provide additional training to caregivers, and review its processes for requesting GP assistance. In addition, she recommended that the local DHB consider continuing to monitor the care and services provided at the rest home.

The full report on case 19HDC00188 is available here.