Woman’s wounds contained maggots

A 71-year-old woman died of sepsis after her leg ulcers became so infected while in a rest home that there were maggots in them.

She was a resident at a Care Alliance Limited rest home, which was found in breach of the patients’ rights code for ‘‘failures in its care’’ in a report released yesterday by Deputy Health and Disability Commissioner Rose Wall.

Ms A, who previously had her left leg amputated, was discharged from hospital to the rest home in 2015.

She had ‘‘high’’ and ‘‘complex’’ needs which predisposed her to wounds, and had multiple ulcers when she was admitted to the home, the report stated.

During her time in the rest home, she developed further wounds which were not appropriately assessed or cared for.

Clinical records repeatedly referred to Ms A’s ‘‘malodorous’’ (foul-smelling) wounds during dressing changes, but there was no documentation to show ongoing assessment of the wounds overall, the report stated.

After about six months at Care Alliance she was found ‘‘weak but . . . responding’’. The following day she was unresponsive and an ambulance was called.

In hospital, a nurse recorded Ms A’s leg amputation site was necrotic (dead), and there were maggots present.

It was noted that maggots were also found in Ms A’s right foot wounds, and that her right toes all had necrotic tissue.

In March 2017, Care Alliance Ltd sold the rest home to a new owner. The two companies share no connection, the report stated.

The Health and Disability Commission sought further information from the director of Care Alliance Ltd, who advised he had no relevant information about the rest home ‘‘because he no longer had possession of his laptop where the information was stored, nor was the information stored elsewhere’’.

Wall found Care Alliance Ltd breached the code because it failed to provide services to Ms A with ‘‘reasonable care and skill’’.

‘‘She would have experienced significant pain . . . which could have been avoided.’’ Report by Deputy Health and Disability Commissioner Rose Wall

Ms A did not receive appropriate assessment and care of her ‘‘numerous’’ wounds while in their care, Wall said.

‘‘She would have experienced significant pain as her condition deteriorated which could have been avoided’’ if managed more effectively, she said in the report.

Wall was also ‘‘highly critical’’ the organisation did not have important information relevant to her care securely stored.

Wall recommended the company provide a written apology to Ms A’s family.

She also recommended the rest home’s current owners provide evidence of relevant changes and conduct an audit regarding wound care plans and incident forms.