Source: Radio New Zealand
A standing hoist was not used because of safety concerns due to Mr B’s violent swaying and involuntary body movements. File photo. Bret Kavanaugh / Unsplash
A man with multiple sclerosis died from choking while being fed by a healthcare assistant sitting up in bed.
A Health and Disability Comissioner (HDC) report by Carolyn Cooper looked into the events, after his family made a complaint following his death amid concerns about his overall standard of care.
The man – named Mr B in the report – was aged in his late 20s and had lived at Lonsdale Total Care Centre in Foxton for about six months before his death in May 2022.
As well as multiple sclerosis, he was diagnosed with mental health co-morbidities, was sight-impaired and required assistance for all aspects of daily living – including to feed and reposition himself.
The family’s complaint queried why he was not showered for the six months he was there – but Lonsdale explained it was because he had requested not to be showered, and preferred to be washed daily, despite attempts by staff to encourage showering.
The hoist
In their initial complaint, Mr B’s family questioned why he was confined to his bed due to a broken hoist.
Up until late March of that year, Mr B was lifted out of bed on request – usually to smoke, which the home believed was important for his mental health – and that was usually done with a hoist.
But Lonsdale said that at no point was a standing hoist unavailable, but it was not used because of safety concerns due to Mr B’s violent swaying and involuntary body movements.
The HDC report concluded: “It is my view that Lonsdale has provided a plausible explanation of why these issues occurred, and I acknowledge that the staff were respecting Mr B’s wishes.”
The choking incident
Lonsdale noted Mr B had choked once before, and a plan was made for him to sit upright when eating to mitigate the risk.
However, Lonsdale told the HDC: “It is a fair question if more should have been done to recognise and mitigate the risk of choking, in particular by referring [Mr B] for specialist assessment. It’s one we have asked ourselves.”
Recommendations
The HDC found Lonsdale in breach the Code of Health and Disability Services Consumers’ Rights, and was critical that Mr B’s risk of choking was not identified earlier and made part of a more comprehensive care plan.
Lonsdale has accepted this finding.
Ms B, who is Mr B’s mother and the one who laid the complaint, responded that she regretted placing Mr B in their care.
A registered nurse, who was asked to give feedback on the situation for the HDC report, said: “It appears that the care team knew Mr B well and were responsive to his needs; however, I consider the lack of personalised care guidance to have potentially created increased risk, particularly for those who were not familiar with Mr B’s care requirements.”
Since the incident, Lonsdale had made a number of changes to improve documentation and evaluations for those in their care.
The HDC report commended Lonsdale for apologising to Mr B’s family and for the prompt improvements, and made no further recommendations.
Approached by RNZ for further comment, Lonsdale general manager Mark Buckley said the team strove to provide the highest level of quality care to all their residents.
“All of us here at Lonsdale continue to extend our sincere condolences to our resident’s family,” he said. “This was a distressing event for everyone involved.”
Since the event in 2021, they had worked to improve aspects of care such as planning, communication and documentation, along with a change of GP practice to a more ARRC (Age-Related Residential Care Agreement) focused provider and the upgrade of patient management software. A clinical manager and additional management support were appointed in 2022.
“We continue to do all we can to make sure that an incident like this can’t happen again.
When approached by RNZ for further comment, Lonsdale general manager Mark Buckley said the team strove to provide the highest level of quality care to all their residents.
“All of us here at Lonsdale continue to extend our sincere condolences to our resident’s family,” he said. “This was a distressing event for everyone involved.”
Since the event in 2021, they had worked to improve aspects of care such as planning, communication and documentation, along with a change of GP practice to a more ARRC [Age-Related Residential Care Agreement] focused provider and the upgrade of patient management software. A clinical manager and additional management support were appointed in 2022.
“We continue to do all we can to make sure that an incident like this can’t happen again.”
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– Published by EveningReport.nz and AsiaPacificReport.nz, see: MIL OSI in partnership with Radio New Zealand
