Names have been removed to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person’s actual name.
Complaint background
This Office received a referral from the Associate Coroner about the care provided to Mrs A at Heritage Lifecare Limited (operating as Clutha Views Village), located in Balclutha, Otago. The referral highlighted concerns about Mrs A’s wound care management, a lack of early escalation to her general practitioner (GP) when the wounds were deteriorating, her continence management, pressure injury management, and the adequacy of her assessments and care plans. I express my sympathy and heartfelt condolences to the family and friends of Mrs A for their loss.
Background
Mrs A, aged 61 years at the time of events, had a complex and extensive medical history, including congestive heart failure, atrial fibrillation, bariatric surgery, type 2 diabetes, a craniotomy with residual left-sided weakness, and deep vein thrombosis. Mrs A, although relatively young, was a particularly vulnerable consumer on account of her comorbidities and, in the two years before her death, had been largely bed-bound and therefore dependent on others for her cares. Despite her chronic health issues and high needs, Mrs A had been cared for at home by her husband with the support of district nurses up until the time of these events.
In mid-January 2022, Mrs A sustained a skin tear and haematoma to her left leg when her dog jumped on her. On 27 January 2022, Mrs A underwent a debridement[1] of her leg wounds to remove dead tissue, and a donor skin graft was put in place to assist with healing. The surgery was performed at the local public hospital.
On 28 January 2022, Mrs A was transferred from hospital to a community-owned healthcare provider in Clutha, where she stayed for several weeks for rehabilitation. On 22 February 2022, Mrs A was discharged from there to Clutha Views Village for further convalescence and social support while her wounds healed as a precursor to returning home. Instructions from the community-owned healthcare provider were that Mrs A’s skin graft wound dressing was to be changed twice a week. On review of the information gathered over the course of this investigation, it is evident this did not occur.
Despite her extensive medical history, it appears that Mrs A’s healthcare assessments were not completed in a timely and comprehensive manner to enable appropriate person-centred care plans to be formulated. This was counter to Heritage Lifecare’s Care Planning Policy and Procedure (2021), which directed that a Registered Nurse was to undertake an assessment and develop an initial care plan for each resident within 24 hours of their admission and a long-term care plan within 21 days of admission. Short-term care plans were to be developed to cover any short-term needs (expected to resolve in four to six weeks). The management of Mrs A’s skin grafts would fall into this category.
On the morning of 3 April 2022, some six weeks after being admitted to Clutha Views Village, Mrs A was having trouble breathing, and nursing staff contacted Dr B, who worked in emergency medicine at the community-owned healthcare provider, seeking permission to give her oxygen. The nursing staff also told Dr B that Mrs A had had some difficulty swallowing for the past two weeks, had not been eating much, and had little urine output.
When Dr B reviewed Mrs A at Clutha Views Village, she found very smelly and infected wounds on both her legs and that one of the dressings had not been changed since 24 March 2022 (10 days).
Review of the records showed that the instructions from Clutha Health First on transfer to change Mrs A’s wound dressings twice weekly had not been followed. Heritage Lifecare’s Wound Assessment and Management Policy and Procedure (2021) was also not followed. This policy provides that, when a resident is admitted with an existing wound, a Registered Nurse is to complete a wound assessment on admission and develop a short-term care plan for managing the wound. The policy states that wound management plans must be adhered to and updated at every dressing change and photos taken every week. If the wound appears infected, it should be escalated to the GP with the resident’s vital observations. If there are signs of infection, such as a bad smell, or purulent exudate (pus), then a wound swab should be sent to the laboratory. From the information gathered, it seems that neither the instructions from the community-owned healthcare provider nor Heritage Lifecare’s own wound care policy were followed.
Dr B also noted that Mrs A’s urine (which was collected via a urinary catheter) was completely opaque (not transparent) and grey. Heritage Lifecare’s Indwelling Catheter Policy (2021) provides information on the fluid monitoring required, how often the catheter bag is to be emptied, and what should be recorded in the resident’s long-term care plan. In this policy, a Registered Nurse is responsible for monitoring and maintaining a resident's urinary catheter and reporting any abnormalities (such as cloudy or offensive-smelling urine) to the GP. On review of the information, it appears that this policy was not followed, and Mrs A’s drop in urine output two weeks earlier had not been escalated to the GP.
On Mrs A’s arrival at the community-owned healthcare provider, she was documented as having multiple pressure injuries at the base of her spine. Heritage Lifecare’s Pressure Injury Prevention and Management Policy and Procedure (2021) provides that a skin integrity and pressure injury risk assessment is to be completed on the day of admission and that the resident’s comorbidities are to be considered; for example, whether they have diabetes, malnutrition, incontinence, obesity, etc. This information is to be included in the resident’s initial care plan. It appears that this policy was not followed. This is particularly concerning considering Mrs A’s history of type 2 diabetes and the potential it had to compromise her health if poorly managed.
Dr B considered that Mrs A’s deterioration and the state of her dehydration and highly concentrated urine could not have happened solely over the course of that morning. Dr B went on to comment that it was difficult to say if Mrs A’s clinical care was poor, however she was surprised not to have been called earlier, and it was fair to say that Mrs A’s overall state of health was markedly poor (when she saw her).
In the afternoon of early April 2022, Mrs A was diagnosed with renal failure and sepsis[2] and, very sadly, passed away.
The Coroner’s referral
The Coroner investigated Mrs A’s case to determine the cause and circumstances of her death and found:
‘It is apparent to me from the circumstances of this case that Mrs A received suboptimal health care services in the weeks prior to her death while she was at Clutha Views Village. This has been accepted by Heritage Lifecare …’
Response from Heritage Lifecare Limited
In its response to the Coroner, Heritage Lifecare Limited acknowledged the following failures in the care provided to Mrs A.
Assessments were deficient.
Care plans were not completed.
Wound care charting was ‘vague in nature’ and did not follow instructions from the community-owned healthcare provider.
Dressings were changed sporadically with gaps of up to seven to ten days between dressing changes.
Urinary output was variably monitored.
There was no evidence of escalation to the GP regarding urinary output.
In addition, I consider a more holistic approach to Mrs A’s care while she was a resident at Clutha Views Village was absent and in addition to the listed shortcomings above it seems there was also insufficient attention given to the management of her nutrition needs (noting her history of type 2 diabetes and bariatric surgery), and the risks to her health on account of her impaired circulation and poor mobility.
Responses to provisional decision
Heritage Lifecare Limited
Heritage Lifecare Limited was given a copy of the provisional decision including the proposed findings and recommendations. Heritage did not have any further comments to make.
Mr A
Mr A was given the opportunity to respond to the provisional decision; however, HDC did not receive a response.
Decision — breach
This investigation is focused on whether Heritage Lifecare Limited (operating as Clutha Views Village) provided Mrs A with an appropriate standard of care between 22 February and 3 April 2022, inclusive.
I am concerned at the standard of care provided to Mrs A during her brief time as a resident at Clutha Views Village. In my opinion, the issues outlined above reflect systemic failings in the delivery of care to a resident with a complex medical history, high needs and at particular risk of deterioration. Mrs A was reliant on nursing staff ensuring timely assessments were undertaken with comprehensive care plans formulated to ensure her needs were consistently met by all staff caring for her. It also required Mrs A’s health to be carefully monitored and for Clutha Views Village staff to escalate issues of concern promptly in the event problems developed. There were multiple instances where staff did not adhere to Heritage Lifecare’s internal policies. The absence of consistent, coordinated, and responsive care fell well below accepted standards and is deeply concerning.
Right 4(1) of the Code of Health and Disability Services Consumers’ Rights (the Code) states that “Every consumer has the right to have services provided with reasonable care and skill.” In the circumstances, having reviewed all the information available, and with reference to my findings above, I consider that Heritage Lifecare Limited (operating as Clutha Views Village) did not provide services to Mrs A with reasonable care and skill and breached Right 4(1) of the Code.
Changes made since events
Heritage Lifecare Limited told HDC that it has since provided training sessions for its staff in the following areas:
Continence management (in-dwelling and supra-pubic catheter management).
Wound care and management.
Completing assessments.
In addition, Heritage Lifecare Limited told HDC that it reviewed its Hygiene and Grooming Policy and Procedures and its Care Planning Policy.
Other comment
According to HealthCERT, the regulator responsible for the certification of rest homes, Heritage – Clutha Views is currently certified for a period of three years from 16 November 2023 to 2026. The most recent audit completed was the March 2025 unannounced surveillance audit, which resulted in three subsections as partially attained (four criteria, with two subsections rated as moderate risk and one subsection rated as low risk). The two subsections rated as moderate risk had findings relating to the care planning (timeliness of assessments, evaluation and EPOA/family involvement) and call bell response times. The one subsection rated as low risk had a finding relating to staff training.
The events occurred in early 2022, and in the intervening period there has been opportunity for Clutha Views Village to remedy the deficiencies in care identified in this report and to monitor the effectiveness of the measures introduced. It is concerning Clutha Views Village was partially compliant in the areas of client assessment, care planning and staff training noting these areas contributed to the poor care Mrs A received.
Recommendations
I therefore recommend that Heritage Lifecare Limited (operating as Clutha Views Village):
Report back to HDC within six months of this report on the remedial actions it has taken in response to the surveillance audit findings and its partial attainment in the areas of client assessment, care planning and staff training.
Use an anonymised version of Mrs A’s case for wider education across Heritage’s sites to highlight the importance of assessment, care planning, monitoring and escalation of care. Evidence confirming the content of the presentation and delivery is to be provided to HDC within six months of the date of this report.
Provide evidence to HDC within six months of this report of recent education sessions delivered to staff in the areas of wound care management and continence management (in the form of education/training material and staff attendance records).
Follow-up actions
A copy of this report with details identifying the parties removed, except Heritage Lifecare Limited (operating as Clutha Views Village), will be sent to HealthCERT and Health New Zealand | Te Whatu Ora and placed on the Health and Disability Commissioner website, www.hdc.org.nz, for educational purposes.
Rose Wall
Deputy Health and Disability Commissioner
[1] A medical procedure to remove dead, damaged, or infected tissue from a wound to promote healing.
[2] A life-threatening condition where the body’s response to an infection causes it to damage its own tissues and organs.