Director of Proceedings v Summerset Group Holding Limited  NZHRRT 1, (25 January 2022)
The Director of Proceedings filed proceedings by consent against Summerset Group Holdings Limited, owner and operator of Summerset down the Lane (“Summerset”) in the Human Rights Review Tribunal (“the Tribunal”) regarding the care provided to Miss E.
In December 2016, Miss E, aged 88 years, was admitted to rest-home-level care at Summerset following a hospital admission. At the time of her admission, Miss E’s risk of developing pressure injuries was assessed and considered very high. On admission, Miss E had an arterial ulcer on her left leg, and that day a pressure injury was noted on her right heel. One month later, owing to a decline in Miss E’s general condition, she was assessed as requiring hospital-level care, which was also provided at Summerset. Over the course of her residence at Summerset, Miss E developed a skin tear on her lower calf, a pressure injury to her left heel, and a sacral wound.
During Miss E’s time in rest-home-level and hospital-level care, Summerset failed to provide healthcare services to Miss E with reasonable care and skill. In particular:
- The pressure injury risk assessment undertaken when Miss E was admitted to rest-home-level care was never repeated.
- Throughout her residence, there were delays in identifying, managing, treating, and escalating Miss E’s wounds, such as delays in the commencement of short-term care plans and wound assessment and treatment plans; delays in seeking the review of wounds by external medical and nursing practitioners including a specialist wound-care nurse; a delay of almost a month in commencing a turning chart; the failure to commence catheterisation; and the failure to provide a pressure-relieving mattress.
- On multiple occasions when external nursing and medical assistance was being provided, the practitioners were not provided with the information necessary to fully assess and treat Miss E. For example, Summerset staff failed to advise the practitioners about all of Miss E’s wounds, so that they could all be assessed, and, on one occasion, staff showed a nurse an undated photo of a wound, instead of showing the nurse the wound itself.
- On several occasions, Miss E’s wounds were recorded inaccurately or were not recorded when it would have been appropriate to do so. The wound care documentation recorded the injuries as less severe than they were, or as “static” or “improving” when they were not.
- Miss E was prescribed “as required” pain relief. A care plan completed in December 2016 recorded that, due to her ulcers, she was likely to be in pain. However, during December, there was only one record of Miss E having been provided pain relief during a wound dressing change. Further, during January 2017, multiple entries in Miss E’s care progress notes recorded that Miss E was in pain, but no pain relief was provided
- Staff failed to follow short-term care plans and to report Miss E’s pain to the appropriate staff members.
- Summerset did not keep Miss E’s next of kin informed of the increasing severity of her wounds.
In late January 2017, Miss E was taken to hospital by ambulance. She was diagnosed with sepsis from infected pressure ulcers. Miss E had a nearly circumferential left heel ulcer. Miss E was also found to have Grade III or IV bilateral heel ulcers (ulcers with full thickness loss of skin and/or tissue, often to a level where fat, muscle, tendon, ligament, cartilage, and/or bone is exposed) measuring 7cm and a sacral pressure wound measuring 8cm. Miss E was provided with palliative care and, sadly, passed away two days later.
Summerset accepted that there were deficiencies in the care its staff provided to Miss E, and that it had ultimate responsibility to ensure that Miss E received care that was of an appropriate standard and complied with the Code of Health and Disability Services Consumers’ Rights (“the Code”). Summerset accepted that its failures in care amounted to a breach of the Code, and the matter proceeded by way of an agreed summary of facts. The Tribunal was satisfied that Summerset failed to provide services to Miss E with reasonable care and skill, and issued a declaration that it had breached Right 4(1) of the Code.
The Tribunal’s full decision can be found at: