Untreated bed sore was fatal

A festering bed sore killed a rest home patient, in part, because staff did not provide care at a critical time in her life, a report has revealed.

Deputy Health and Disability Commissioner Rose Wall criticised a Bupa Care Services rest home and hospital facility in findings released on Monday.

Wall found that staff ‘‘failed to assess, think critically, and act appropriately’’ as the woman’s general condition deteriorated.

As a result, Bupa also failed to help her with ‘‘reasonable care and skill’’ in 2014.

The company has ‘‘apologised unreservedly’’ for the lack of care.

Multiple sclerosis left the woman largely bedridden while suffering from a multitude of other medical conditions.

Zopiclone was prescribed to help with her insomnia, with her doctor increasing the dosage following a check-up.

A staff member noticed an ulcer-like wound forming on her lower back. The area was monitored and re-dressed regularly over seven days.

Nearly six months later her doctor said regular supervision would clear the wound up. However, it began to deteriorate that same evening.

Over the following fortnight, staff noticed the ulcer worsen, along with the resident’s general condition. But the resident was not referred to a wound care specialist nurse or her doctor.

Later that month, staff found the woman unresponsive two days after being administered zopiclone. Her vital signs showed she was ‘‘acutely’’ unwell.

She later died from septic shock, despite urgent surgery at a hospital to remove rotting tissue around the wound.

The actions of the facility’s clinical manager, unit coordinator, and the woman’s nurse in the face of a worsening wound troubled the commissioner.

‘‘This case highlights the importance of aged residential care facilities having staff with adequate expertise and skill to support younger residents with chronic medical conditions and complex [diseases],’’ Wall said.

‘‘Staff must assess, think critically, and respond appropriately to, deterioration in the resident’s condition.

‘‘In my view, the facility failed in its duty of care to Ms A in this regard at a critical time in her life.’’

Wall recommended the rest home improve several of its management policies and systems, and suggested the facility and the three staff members involved write an apology to the woman’s family.

The director of proceedings also filed proceedings against Bupa with the Human Rights Review Tribunal, which declared it breached the woman’s right ‘‘to have good care and support that fits your needs’’.

In a statement, Bupa managing director Jan Adams said the care provided to the resident was unacceptable and well below the organisation’s standards.

Following a review within Bupa, a number of changes had been made, she said.