A healthcare company has apologized for the ‘shocking’ treatment of a diabetic woman who did not receive her usual insulin treatment and died less than 24 hours after being admitted to one of its nursing homes.
Assistant Health and Disability Commissioner Rose Wall has identified consumer rights code violations by Oceania Care Company and two registered nurses involved in the woman’s care in 2018, following a complaint from her daughter.
The woman in her 60s suffered from type 2 diabetes, dementia, asthma and cardiac arrhythmia and was dependent on ‘saving’ time and dose-sensitive drugs including insulin and warfarin, which was noted during their admission assessment.
READ MORE: A woman died a day after arriving at the nursing home, without medicine
An inquest found that she was not given medication that could have managed her blood sugar levels and ultimately prevented her death due to improper admission planning, lack of follow-up on a prescription request with their GP or pharmacy and a culture of poor communication.
The managing director of Clinical and Care Services for Oceania, Dr Frances Hughes, said the woman’s death was a nightmare scenario and the company’s managing director had offered an unqualified apology to her family.
“It’s shocking, it shouldn’t have happened,” she said.
“We’ve done everything we can and invested in our systems and processes and in our education, but ultimately that doesn’t help the pain and suffering this family has been through.”
The woman’s daughter told the commissioner that she was reluctant to institutionalize her mother and that she now feels a “deep sense of regret, self-blame, loss and despair”, and as if she had failed “one of the people [she] the most beloved in the world”.
“Multiple systems issues” were to blame for the woman’s death, Hughes said.
“It’s like Swiss cheese,” she said.
“There are individuals involved, there are systems involved, there are processes involved and at the end of the day we expect more. We have done a lot to prevent this from happening again.”
Oceania’s overhaul included changes to senior management, a new resident management system, the recruitment of nurse practitioners to work between centers and training and professional development for staff, Hughes said.
“I can assure you that the circumstances that allowed this woman to go through what she did and then lose her life to blood sugar and diabetes would not happen today,” she said. declared.
Four nurses involved in the woman’s care were no longer working at the nursing home, but no one in Oceania had lost their jobs, Hughes said.
She declined to name the nursing home at the center of the case.
Deputy Commissioner Wall made a number of recommendations, including that Oceania and the four nurses each write apologies to the woman’s family and that the company review policies and staff guidelines.
She also recommended that the Board of Nursing consider whether the competence of two of the nurses should be reviewed.