After a lengthy investigation, the independent health watchdog this morning released his findings, including “failings in hygiene, wound care and weight management and how they led to a situation that should have been avoided”.
Health and Community Services Complaints Commissioner Associate Professor Grant Davies condemned “poor communication” by those in charge of the man’s care and a lack of support services.
He has made a series of recommendations to improve care for other vulnerable South Australians and demanded DHS apologxjmtzywise to the man and his family.
T2H is a step-down facility for people with disabilities who have been discharged from a long stay in hospital and are awaiting more permanent accommodation.
The man was admitted to the service after being discharged from an un-named regional SA Health hospital, but the Commissioner found he should not have been sent there because his needs were too high and the right supports were not in place.
The case has similarities to that of Ann Marie Smith, who died in hospital in 2020 of septic shock and organ failure after allegedly being left to sit in a cane chair for a year.
In his report, Davies said the SA Ambulance Service (SAAS) crew noted concerns about the care of the man – referred to as Mr D – including “that he had an infected pressure wound, that he was wearing dirty clothing and that he had malodourous body odour”.
Davies said SAAS received a triple zero call on May 31 regarding Mr D “who had increased drowsiness and was not responsive”.
On arrival, they found the man with an infected pressure wound, with patient clinical records stating: “SAAS staff found patient with dirty clothing (had not been changed for a few days). Malodourous body odour and poor personal hygiene due to the negligence of carers.”
“Patient’s case worker and sister report patient has been found in this state (left in faeces and urine (for) prolonged periods of time, with a dirty moist towel over infected wound site),” the notes said.
“SAAS staff also found the wound care of the RN (registered nurse) to be neglectful and subpar…”
Davies said SAAS later provided further information including that:
- Mr D “appeared to be malnourished with a large pressure wound on his jaw”.
- Mr D’s “clothing and underwear were soiled (and) it did not appear as though he had been washed recently with malodourous body odour”.
- The (ambulance) crew were “led to believe that the wound had not been exposed or irrigated on the last visit 3 days prior to SAAS attendance. On the day of SAAS attendance the RN had not fully exposed the site and placed only a saline soaked dressing combine over it.”
In his findings, Davies said the man weighed 57 kilograms – “below his identified healthy weight range” – when he was weighed at the Royal Adelaide Hospital on June 3.
“When SAAS officers attended T2H on 31 May 2021, they thought Mr D appeared to be malnourished,” he said.
“DHS acknowledges that T2H could have done more to monitor Mr D’s weight and agrees that his weight loss contributed to him being a high risk of malnutrition.”
Davies also found that T2H “failed to properly understand and assess Mr D’s health and needs and implement a care plan which identified and incorporated things such as mobility, hygiene, nutrition and hydration and pressure area care”.
He said it was “not appropriate” for the man to be admitted to T2H “as the level of his disabilities meant that he required total assistance in the areas meal preparation, feeding, toileting/continence, bathing, dressing, grooming, medication, bed linen, transfer and pressure area care which T2H demonstrated that it was not able to fully meet”.
The Commissioner made 13 recommendations including that T2H “apologise to the man and his family for the inadequate care he received”.
He also recommended that hygiene and care be assessed on admission to T2H for all patients, and checked regularly throughout their stay.
In addition, he called for T2H to establish a “Health Monitor” to conduct “regular and documented health and welfare checks of each person admitted to T2H to ensure they are being adequately cared for”.
The findings have prompted an immediate apology from the boss of the Human Services Department and a promise to fix the problems.
In a statement, DHS chief executive Lois Boswell said: “The Department of Human Services (DHS) has accepted the Commissioner’s findings and is genuinely sorry that the client did not receive the level of support and care expected.”
“DHS has formally apologised to the client and their family and accepts it should have been more proactive in ensuring the external NDIS nursing agency attended to provide the wound care required,” she said.
Boswell said the department was already implementing the Commissioner’s recommendations, “including a new management structure and an onsite Team Leader who is authorised to take any action appropriate to ensure clients receive the care they need”.
