A diabetic woman died less than 24 hours after she was admitted to a rest home because she did not receive the life-saving medication she depended on, including insulin, an investigation has found.
Insulin and warfarin were among the woman's medications, so Oceania was "on notice" that she required potentially life-saving medication and regular monitoring, the report said. Photo: 123rf.com
Deputy Health and Disability Commissioner Rose Wall found Oceania Care Company and two registered nurses in breach of the consumers' rights code as a result of the woman's death in 2018.
The woman in her 70s, referred to as Mrs A in the report, suffered from dementia and type 2 diabetes and was reliant on time and dose-sensitive medicines, including insulin and warfarin.
She was admitted to the rest home at 1pm, but when Mrs A's daughter returned that evening and used a personal blood sugar monitor the level was high, indicating she needed urgent attention.
The woman asked the nurse on duty to administer her medicine, but the doctor was yet to prescribe it so she gave her mother a dose of insulin herself.
A fax had been sent to Mrs A's GP seeking prescription details for her essential medications, but rest home staff failed to follow up the request with the doctor, medical centre or pharmacy in a timely manner.
The doctor told the deputy commissioner there was no record of the fax being received by the centre.
No blood sugar readings were taken by nursing staff that day.
Mrs A was checked by a nurse at 6.05am the following morning. The nurse found her in bed snoring, but when she checked again just half-an-hour later she found the woman unconscious and called for an ambulance.
Mrs A died in hospital at 7.55am - an autopsy listed her primary cause of death as hyperosmolar hyperglycaemic nonketotic syndrome.
Daughter feels 'regret, hopelessness' over mother's death
The woman's daughter complained to the commissioner that her mother had been consciously and carelessly neglected at the rest home, despite being under hospital-level care.
She said she was reluctant to put her mother in residential care and now feels a "deep sense of regret, self-reproach, loss, and hopelessness", and as though she failed "one of the people [she] loved most in this world".
She also questioned why Oceania did not carry out an internal investigation following her mother's death.
The deputy commissioner found the care provided to the woman fell short of acceptable standards in a number of areas in a time frame of less than 24 hours.
Mrs A's admission assessment noted she was taking warfarin and insulin, so Oceania was "on notice" that she required potentially life-saving medication and regular monitoring, the report said.
"Mrs A did not receive a prescription or verbal order for life-saving medications and, tragically, did not receive medications that could have managed her blood-sugar levels and ultimately prevented her death," Wall found.
At least three of the four nurses involved in her care failed to fulfil their clinical responsibilities and adhere to policies and procedures, she said.
"Policies are of little use if they are not followed by staff," the report said.
"There was a complete lack of critical thinking on the part of the nursing staff involved."
Wall made a number of recommendations, including that Oceania and four nurses involved in the case each write an apology to the woman's family, and the company review its policies and guidance for staff.
She also recommended the Nursing Council consider whether the competency of two of the nurses should be reviewed.
Oceania's general manager of clinical and care services Dr Frances Hughes said the company unreservedly apologised to the woman's family for the considerable distress her death had caused.
"We deeply regret the events that occurred during the resident's final days at one of our sites in 2018," she said.
Hughes said Oceania's senior management had changed, a new resident management system had been introduced and nurse practitioners had been recruited to work between centres in the area.