C22HDC00499 – Summary, findings and recommendations of Deputy Health and Disability Commissioner
This case highlights systemic failures across services in recognising and responding to elder abuse risks, particularly where care occurs within a family setting. The Commissioner identified the need for stronger governance, training, communication, and escalation processes to ensure vulnerable consumers receive safe and appropriate care.
Mr A, a man in his 90s with advanced dementia and multiple health conditions, lived with his son (Mr B), who was his primary carer, and Mr B’s partner at Mr B's home. His daughter (Ms D) held enduring power of attorney (EPOA) for personal care and welfare, while Mr B held EPOA for property and finances. Mr A received limited home support services. HealthCare NZ provided Mr A with regular weekly home domestic support, 15 minutes of daily support for meal preparation, and twice-weekly personal care support for hygiene. He also received support and oversight from Older Persons Mental Health (OPMH) at Health NZ. Complex family dynamics meant that Ms D did not have access to the home and Mr B effectively managed Mr A's day to day care.
Three instances of concerns about possible neglect were raised in 2018 and 2019, and on each occasion initial inquiries found no evidence of abuse. The concerns raised were closed without further follow-up by any agency. During this period none of the individual workers involved in Mr A's care escalated concerns about abuse, and to the extent they queried practices in the home they received assurances from the family regarding care arrangements.
In June 2020, after a hospital admission, a home visit by a Health New Zealand social worker (Ms C) revealed concerning living conditions, including restrictive and unusual measures (e.g. locked spaces, environmental controls outside the bedroom, camera monitoring, and use of a wetsuit at night). These issues were not previously escalated despite multiple service providers being involved.
Findings
Health New Zealand (Health NZ) – Breach of Right 4(1)
Health NZ failed to provide services with reasonable care and skill due to systemic issues, including:
· Poor record-keeping and case management continuity
· Lack of adequate staff support and supervision
· Gaps in processes for identifying and escalating elder abuse concerns
These failures contributed to missed opportunities to detect and respond to potential neglect.
HealthCare NZ – Breach of Right 4(1)
HealthCare NZ failed to provide services with reasonable care and skill, including:
· Failure to involve Ms D in care planning despite her legal authority
· Failure to provide adequate clinical leadership and training to enable care staff to identify and act on clear warning signs of possible neglect or abuse (including concerns arising from unusual care practices, restraint, and restricted family access).
Health NZ Social Worker (Ms C) – Adverse comment
Ms C acted appropriately in identifying concerns and notifying relevant parties. However:
· She followed instructions to step back, limiting further action
· She made an error by disclosing confidential information, affecting safeguarding actions
· She lacked adequate professional supervision and organisational support
Overall, mitigating factors reduced individual culpability.
Recommendations
For Health NZ:
· Provide a formal apology
· Conduct audits of:
o Clinical file quality and timeliness
o Staff supervision practices
· Implement improvements based on audit findings
For HealthCare NZ:
· Provide a formal apology
· Strengthen systems by:
o Adding alerts for EPOA involvement and potential abuse indicators
o Ensuring follow-up assessments where concerns arise
· Update training and resources to include:
o Identification of restraints and environmental risk factors
o Recognising “normalised” but unsafe care practices
· Revise guidance materials to include environmental and contextual warning signs
The Commissioner acknowledged improvements implemented by Health NZ and HealthCare NZ in the six years that had passed since the events in response to the issues identified in this investigation.
For Social Worker:
· Provide an apology to Ms D