Deadly fall at rest home after woman left alone on toilet

A caregiver at a Christchurch rest home left a frail, elderly woman alone on a toilet before she fell, broke her hip and wrist and died in hospital days later.

The woman had been identified as being at risk of falling just hours earlier and had already had a fall that same day at Chatswood Retirement Village, in Opawa.

It is one of two incidents at rest homes to be criticised in scathing reports released on the same day by the Health and Disability Commissioner.

The other case involved a woman’s unexplained injuries being “passively neglected”, and treated as being a result of self-harm, though they were actually from a physical assault by other residents that could have been prevented, an independent investigation found.

In the Christchurch case, which occurred in 2020, after the first fall a handwritten short-term plan was created by a nurse, which stated to “not leave her unattended until she is safely back on her chair or bed”. The unnamed caregiver, who rarely worked in the resthome wing, said she couldn’t remember being told of the plan after a quick verbal handover from the previous shift’s worker. That night, during the final medication round, the caregiver responded to the woman’s call bell and helped her to the toilet.

Not wanting to leave the medication unattended, the caregiver said she would be back in minutes and returned to her round. Next time the caregiver saw the woman she was on the floor, and after a nurse’s assessment she was promptly taken to hospital with a fractured hip and wrist. She died days later.

Aged Care Commissioner Carolyn Cooper has since found Chatswood Lifecare Limited was in breach of the Code of Health and Disability Services Consumers' Rights.

Cooper noted the rest home didn’t review the frail and deteriorating woman often enough, didn’t ensure the shortterm plan was passed to the caregiver, and had conflicting policies.

The caregiver has since apologised to the woman’s family, as has Chatswood Lifecare Limited. The company has also reviewed its handover process and installed a system to support caregivers during medication rounds.

A spokesperson for Chatswood Retirement Village said it “deeply regrets” the incident and had apologised to the family.

“The site has implemented robust measures to ensure resident safety and prevent this incident from recurring. We acknowledge that this has been very depressing for the family as well.”

In a second report, Cooper also found service provider Ultimate Care Group, which has rest homes across the country, had also breached multiple rights of the code in its care of a vulnerable resident with advanced dementia. The woman’s son was concerned that an internal investigation into unexplained injuries failed to find a cause and concluded that they could be the result of self-harm.

A later independent investigation by Te Whatu Ora found that several of the woman’s injuries were likely caused by assault from other residents, and that the provider failed to ensure her safety.

Cooper said it was “unacceptable” the woman’s injuries were not documented, reported, or investigated appropriately.

She was also critical carers failed to recognise that the woman was steadily losing weight, did not make appropriate risk assessments, the facility had a culture of accepting concerning behaviours, and complaint standards were not upheld.

Four rights of the code had been breached in the incident, and Cooper recommended the carers provide a written apology, report missing clinical records to the Privacy Commissioner, and use this case as a basis for more staff training.

Ultimate Care Group has since implemented a new digital records system, reviewed and updated its complaints procedures and a new structure has been put in place with focus on monitoring resident e-files and giving real-time feedback to managers.