Director of Proceedings v Radius Residential Care Limited [2022] NZHRRT 29, (16 August 2022)
The Director of Proceedings filed proceedings by consent against Radius Residential Care Limited (“Radius”) in the Human Rights Review Tribunal (“the Tribunal”) regarding the care provided to a woman while she was a resident at Radius Elloughton Gardens (“REG”).
The woman, 79 years of age at the time of these events, had been a resident in a hospital-level wing at REG since early 2017. She had several comorbidities including an intellectual disability, bipolar disorder, anaemia, congestive heart failure, osteoarthritis, osteoporosis, and a previous fracture to her left fibula. The woman required assistance with most aspects of her daily living and had limited communication ability. The woman used a four-point walking frame when mobilising and required assistance to mobilise from her bed or chair.
Sometime between 9 and 10 November 2018, the woman sustained serious injuries whilst residing at REG. The woman’s progress notes document that at 7.48pm on 9 November 2018 she had been assisted with washing and changing, and had been settled to bed. A health care assistant (“HCA”) said that she provided cares for the woman at 1.30am and 4.30am, but neither of those cares were documented. The HCA documented that the woman had a bowel motion at 6.01am but later denied that this had occurred and could not explain why she had made the entry into the woman’s records. All other staff rostered and working on the night shift between Friday 9 November 2018 and Saturday 10 November 2018 denied that there were any incidents involving the woman during their shift. There were no further entries in the woman’s progress notes or charts until 9.34am on Saturday 10 November 2018.
A nurse who was preparing medication for the morning medication round on Saturday said that she overheard a conversation between two of the night-shift HCAs about a fall that had occurred overnight. The two HCAs involved in the conversation denied that it occurred. The nurse said that she had a brief conversation with the woman during the morning medication round and that the woman was fine and had no complaints of pain. The nurse said she did not notice anything unusual about the woman’s condition. At approximately 9.30am, the nurse was informed that there was something unusual about the woman. The nurse checked the woman and found that she was half dressed in her bed with a care staff member attempting to put a top on her. The nurse said that the woman was screaming and yelling because she was in pain, and refused to let the nurse touch her. This was unusual for the woman, who was usually compliant and cooperative.
The nurse attempted to complete a head-to-toe review of the woman, who indicated that she had pain and redness on her right upper arm, and that the pain score was 9 out of 10. The woman also complained of pain (5 out of 10) in both legs, and could bend both knees around 35 degrees. Subsequently, the nurse arranged for the woman to be reviewed by a GP, who advised that the woman needed to go to Accident and Emergency for X-rays and further assessment. At 2.40pm, an ambulance arrived at REG to collect the woman. Following assessment by hospital staff, the woman was found to have suffered a right shoulder dislocation and a periprosthetic fracture of her left tibia and fibula. The woman’s shoulder was re-located and a plaster cast was put on her left leg. Subsequently, the woman’s niece was told that the woman was in palliative care, and would not walk again.
A formal internal investigation completed by REG failed to gather sufficient information to explain the woman’s injuries. The only confirmed findings included that the woman was well at 8pm on Friday, that her shoulder injury was first detected at around 9.30am on Saturday, her fractured leg was detected later that day at the hospital, and that after sustaining her injuries the woman could not have returned to her bed without considerable assistance from another person or persons. The investigation also noted that at the time, the only people in the facility were staff and residents. A later external investigation found that the woman’s injuries were the result of a fall, or the attempt to lift/pull the woman off the floor to return her to bed, and that it was more likely than not that the incident occurred when one of the HCAs took the woman to the toilet at 6.01am.
Radius accepted full responsibility for the sub-optimal care provided to the woman, and acknowledged that it had ultimate responsibility to ensure that the woman received care that was of an appropriate standard and complied with the Code, and that it failed in that responsibility. The Tribunal was satisfied that Radius failed to provide services to the woman with reasonable care and skill, and issued a declaration that the defendant breached Right 4(1) of the Code.
The Tribunal’s full decision can be found at: