Rest home fails to recognise delirium and provide pain relief to elderly woman


Rest home fails to recognise delirium and provide pain relief to elderly woman

Health & Disability Commissioner
2 minutes to Read

Deputy Health and Disability Commissioner Rose Wall today released a report finding a rest home in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failures in the care of a woman in her nineties.

The woman was admitted to the rest home in 2019. She had a number of health issues that limited her mobility and caused her significant pain. She had the capacity to make decisions for herself, and had expressed that she was reluctant to go to hospital.

The woman developed a skin infection and was prescribed antibiotics, and her dressings were changed regularly. However, over two days, the woman’s health deteriorated rapidly; she ate and drank less, was in pain, became less coherent and more sleepy. The registered nurses recognised these changes in the woman but took no action. While providing assistance to the woman a physiotherapist noticed the changes and referred her for immediate review by a doctor.

The doctor noted that the woman was delirious and sent a referral to the hospital. There was a delay in calling an ambulance, and then she was assigned as a low priority call as rest home staff assumed she would be okay if there were more urgent cases that required ambulance care.

While waiting for the ambulance, the woman’s daughter arrived and discovered her mother in a lot of pain with discoloured feet. The ambulance arrived three hours after the initial referral to hospital. When the woman arrived at hospital she was diagnosed with sepsis due to cellulitis and reduced blood supply to her legs. Sadly, she did not respond to treatment and died.

The Deputy Commissioner considered that the rest home did not provide appropriate care to the woman. They failed to recognise and assess her sudden onset of delirium, arrange alternative pain-relief measures, and monitor her food and fluid.

"There are two concerning features with the care. First, even though nursing staff noticed and documented changes in the woman’s condition, such as confusion, disorientation, and lethargy, there was a lack of critical thinking that this could indicate a deterioration in her health," Ms Wall said.

"Secondly, owing to the lack of recognition of the significance of the woman’s symptoms, nursing staff failed to respond and escalate her deterioration in a timely manner. As a result, the woman experienced unnecessary pain and suffering."

Ms Wall also criticised the lack of an Advance Care Plan to ensure her end of life wishes were taken into account.

She recommended that the rest home implement an electronic health record system; carry out an audit of patient records for staff compliance with rest home policies; provide training to staff on relevant topics; and schedule regular and ongoing refresher education for all nursing staff on topics including delirium and sepsis, escalation of care, advanced care plans, documentation and hydration.

She also recommended the rest home apologise to the woman’s family.

The full report on case 19HDC02274 can be found on the HDC website.