Human Rights Review Tribunal, NZHRRT 070/2015 (23 November 2015)
The Director brought proceedings against Radius Residential Healthcare Ltd (Radius) in the Human Rights Review Tribunal. The proceedings were resolved by way of negotiated agreement involving a declaration by the Tribunal that Radius did not provide services to Mr A with reasonable care and skill with regard to Mr A's assessment on admission, his care planning and wound care, and a lack of adequate assessment and follow-up of his change in health status. The Tribunal found that Radius breached Right 4(1) of the Code.
Mr A, then aged 70 years, was admitted to respite care at Radius St Winifred's Hospital for just over two weeks. Mr A had multiple co-morbidities, including type II diabetes. Mr A's left leg had been amputated below the knee, and his right foot had two chronic infective ulceration wounds on his big toe and heel. These wounds had been managed in the community for two years. In addition to the two ulceration wounds, Mr A had a skin tear on his right leg.
Mr A did not receive adequate care during his stay at Radius St Winifred's. Upon admission, Radius staff did not complete adequate risk assessments (including falls risk and pressure sore risks) and care plans for Mr A's wounds. Basic observations were not carried out. No wound care plan was put in place on admission for Mr A's wounds on his right toe, left leg or left stump. Once identified, the wounds were not reviewed regularly. Mr A did not receive dressing changes for his wounds at the frequency required by the existing wound care plans.
During his time at Radius St Winifred's, Mr A's right foot wounds deteriorated, particularly his right big toe, which became necrotic. Nursing staff did not respond to the change in Mr A's toe wound adequately. Mr A's family and GP were not informed of his change in health status and medical assistance was not sought.
Two days following his discharge from Radius St Winifred's, Mr A was admitted to Christchurch Hospital, presenting with gangrene of his right big toe. Mr A's right leg was amputated above the knee on 13 July 2012.
The Tribunal's full decision can be found at:
Last reviewed February 2019