When Dave Appleton’s mum fractured her arm during a rest home incident, he thought it was a one-off.

Appleton and his family visited regularly, often taking the children to see her for a “cuppa” on weekends.

He didn’t have any reason to suspect Audrey Wilson, an “awesome mum” who “loved her family and her garden”, wasn’t getting proper care at Elmswood Care Centre, an Oceania Healthcare facility in Tauranga.

When his mother hurt her arm he was frustrated staff had taken so long to let them know but was given assurances the team were monitoring her and had a plan in place.

So he was shocked when he arrived for a visit in March 2021 to find her hot and unresponsive.

“She was basically crashed out on a chair.”

Appleton asked for someone to call an ambulance but said a nurse told him his mother should be assessed by a doctor first. He responded in firm terms that he would be calling an ambulance.

His mother was admitted to Tauranga Hospital where her right leg was found to be swollen and hot with redness, with a small skin tear on her shin.

She was diagnosed with septic shock and cellulitis. While her condition temporarily improved after antibiotics, she passed away 10 days later.

Appleton referred his mother’s care to the Health and Disability Commission which recently found she had been given substandard care by staff at Elmswood, including failing to properly update Wilson’s family about her deteriorating condition and need for advanced care.

Appleton said he had trusted the staff to give his mother, who had complex needs and dementia, the specialised care he and his family did not have the skills to provide.

He wished he had pushed for more communication and information from the Elmswood staff while she was there− both over the phone and when he visited.

“You’re trusting them to look after your elderly parents,” he said.

“You can’t talk to mum about it... You know, ‘How’s it all going, mum? Are they looking after you?' You just don’t know because she’s got dementia, she doesn’t know what she’s talking about.”

Concerns raised by mental health services

Wilson was in her 70s when she became a resident at Elmswood.

Her dementia made her aggressive and agitated, particularly when she was being cared for by staff, and Elmswood notes provided to the HDC revealed it would often take three staff to do her “cares”.

She was assessed by Mental Health Services for Older People (MHSOP) while she was a resident, and concerns were raised that she needed “psychogeriatric level” care.

However, the staff felt that moving her would make her more unsettled, and “were keen to try and manage her at Elmswood”.

One of the criticisms in the HDC findings was that the staff would do “personal cares” for Wilson at night when she was “sleepy and less resistive”.

HDC Aged Care Commissioner Carolyn Cooper criticised Elmswood for not adequately communicating the concerns raised by Mental Health services to Wilson’s family.

“Adequate communication with the family is important in situations where the consumer is cognitively impaired and family are part of the support network,” she said.

“The ability of Elmswood to provide Mrs Wilson with the standard of care she required in addition to the changes in her medication (and the potential risks to her mobility and sedation levels) were significant issues that needed to be discussed with [her enduring power of attorney] and whānau."

Appleton said he had not been aware of the seriousness of his mother’s condition and told the HDC that if he had, he’d have requested she be transferred.

Aged Care Commissioner Carolyn Cooper.

A series of injuries

During Wilson’s time at Elmswood she had a series of injuries, the first being an arm injury for which no care plans were documented, assessments were delayed, and there had been poor communication with her family.

Wilson was grabbed by another resident and then banged her hand against a window. She had some bruising and swelling, and was given paracetamol, but it took two days for her family to be told.

They took her to the hospital and she was found to have a fracture.

The HDC concluded this event should have been treated more seriously, and the family informed immediately.

Several months passed, and then Wilson had two unwitnessed falls within a few days of each other.

She was noted to be lethargic and needed help to eat lunch, but her vital signs were stable and her family were told about the falls. She was also observed to have redness and swelling in her legs, which were weeping clear fluid.

However, the HDC said there was a “lack of critical thinking” in the care following the falls.

No efforts were made to ensure her legs were elevated, and there had been a lack of assessments and observations.

The HDC said there had been a presumption made that Wilson’s behaviour was “usual” which meant they failed to address her deteriorating condition.

“Plans for wound care should have been in place, [her] falls risk assessment should have been updated following the unwitnessed falls... and short-term care plans for medication management and monitoring should have been in place, with appropriate escalation in response to her deteriorating condition,” Cooper said.

Overall deficiencies in care

Cooper concluded there had been a “pattern of suboptimal care and a lack of critical thinking from staff members”.

The nurse who had been on duty on the day Wilson was admitted to hospital was also found to have been in breach.

She told the HDC that she had made observations of Wilson, who was sitting in the chair in a common area, before her family found her and called an ambulance.

However, Oceania’s internal investigation said CCTV footage suggested she hadn’t made those checks. That footage was not provided to the HDC as Oceania had not retained it, and the nurse disputed its contents.

The nurse told the HDC she had been at Elmswood for less than three weeks and was not provided with adequate training and was expected to learn on the job.

She told the HDC she was, “flustered and overwhelmed with all that was required in caring for 36 residents, all of whom she was unfamiliar with and therefore relied on the healthcare assistants”.

The decision said, “while she considers herself to be a competent nurse, she was working in a new, stressful, and difficult environment with limited training and support and a very busy workload for one registered nurse”.

Cooper concluded that, despite there being no CCTV for her to review, the nurse’s notes also did not support her account of having done regular checks on Wilson.

Cooper said the nurse was experienced, and while she had only recently started working at Elmswood and wasn’t familiar with the residents, she should have identified Wilson’s deterioration.

She said that on the day in question, Wilson had been “left alone for a substantial period”.

“I acknowledge her concerns that she had a very busy workload with complex residents; however, the roster staffing ratios were found to be in line with the Age-Related Residential Care service agreement,” Cooper said.

Both the nurse and Oceania were found in breach of the Code of Health and Disability Services Consumers’ Rights, and Cooper made a series of recommendations.

Cooper said that the deficiencies in the care provided to Wilson were systemic issues for which Elmswood bears responsibility.

“Elmswood had a responsibility to operate the dementia unit in a manner that provided its residents with services of an appropriate standard,” said Cooper.

“The overall deficiencies in care provided in this case demonstrate a pattern of suboptimal care and a lack of critical thinking from staff members.”

Oceania’s director of clinical and care services Shirley Ross said she wished to echo the apology CEO Suzanne Dvorak had given to Wilson’s family.

“We know we did not provide the care expected of this vulnerable resident and her family, and we are now doing what we can to ensure that all families get the level of care they deserve,” Ross said.

They were taking “significant steps to address every recommendation made by the HDC”.

Over the past few years, Ross said Oceania had implemented better management processes, provided staff with additional training and education, and undertaken audits to ensure it didn’t happen again.

Oceania had implemented a new nurse-led primary care model where it employed Nurse Practitioners to provide Primary Care Services to our residents.

As part of this, residents' needs were assessed and plans made if they required more care than a current facility could provide.

The nurse found in breach no longer works in aged care and sent a letter of apology to Appleton.

Hannah Bartlett is a Tauranga-based Open Justice reporter at NZME. She previously covered court and local government for the Nelson Mail, and before that was a radio reporter at Newstalk ZB.