Failures in managing pain and end-of-life care for elderly woman


Failures in managing pain and end-of-life care for elderly woman

Health & Disability Commissioner
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Deputy Health and Disability Commissioner Rose Wall today released a report finding an aged care provider in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failures in its care of an elderly woman.

The woman, aged in her nineties at the time of these events, had a number of health issues including recurrent pneumonia, leukaemia, Parkinson’s disease and a sacral pressure injury. She required full assistance with daily living activities.

Until her death, she was a permanent resident at Waiapu House Lifecare (WHL) run by Heritage Lifecare Limited. This was during a period of organisational instability at the facility with staff turnover and managerial change.
"I consider that the care provided to the woman was inadequate, and resulted in appropriate assessment and interventions not being actioned to manage her pain and end-of-life care," Ms Wall said.

"Ultimately it was Heritage Lifecare Limited’s responsibility to ensure continuous care for her during this time of organisational instability."
The Deputy Commissioner was critical that the woman’s Lifestyle Care Plan was written belatedly and not adopted into her daily care to manage pain. She was also critical that a mandatory interRAI assessment and a Last Days of Life Care Plan was not initiated.

Ms Wall recommended that Heritage Lifecare Limited undertake regular clinical documentation audits; undertake a quality improvement initiative on the use of assessments and care plans; schedule regular and ongoing education sessions for nursing staff on pain management and end-of-life care; use an anonymised version of the report as a case study; update the Allocation of Staff/Duty Rosters policy; and provide a formal written apology to the family.

She noted that WHL has taken a number of actions since these events, including increasing the number of rostered hours for registered nurses and implementing the use of the Last Days of Life Care Plan tool.

The full report on case 18HDC01406 is available on the HDC website.