A woman died of an infection after serious wounds were poorly managed by a resthome and they became infested with maggots.
The case is detailed in a report today by a Deputy Health and Disability Commissioner, Rose Wall.
She said the unnamed woman was admitted to a resthome managed by Care Alliance Limited from a public hospital in 2015. This followed an InterRAI assessment which concluded she needed long-term hospital-level care.
The woman, Ms A, had a background of high health needs, including severe peripheral vascular disease, congestive heart failure and type 2 diabetes. She also had had a left below-knee amputation two years earlier and was using a wheelchair.
When she went into the resthome she had ulcers on her right leg, and five more wounds developed at the resthome. Clinical records five and six months after she went into the resthome made frequent comments about her wounds, being smelly or "malodorous" during dressing changes, "with varying degrees of exudate" [seepage].
Nevertheless, "a care plan for pressure injury prevention was not put in place until Month eight [about six months after she went into the home], and there is no documentation to show that there was ongoing assessment of Ms A's wounds overall."
Ms Wall said Ms A experienced considerable pain during wound reviews and other procedures related to her wounds at the resthome. But, "there is no evidence that any form of pain relief was offered to Ms A prior to dressing her wounds, and there was no specific care plan in place for managing the pain associated with her wounds."
One of her wounds - a pressure sore on her upper left leg - had increased to 6cm by 5cm and 1 millimetre deep but had not been escaled for review, no medical input was obtained and there were no photographs taken of it.
Towards the end of her time at the rest home, Ms A was "weak but not responding". She was admitted to another hospital where a nurse noted there was a "necrotic stump extending over one knee" which had a bad smell and "maggots present". Maggots were also found in her right foot wounds and her right toes also had dead tissue.
Ms A died not long after as a result of sepsis, or infection, from her infected ulcers.
Ms Wall said in her report that inadequate management of Ms A's care and wounds by resthome staff led to her being transferred to the second hospital. She added: "On arrival at hospital 2, Ms A's wounds were noted to be in very poor condition, and the skin between her toes indicated a poor standard of hygiene."
She said it was critically important that staff at the resthome were attentive to Ms A's needs, and Care Alliance Limited had breached patient rights by failing to do this. Instead, Ms A's wounds "had been allowed to progress to such a degree that they were significantly infected. Further, it is concerning that Ms A would have experienced significant pain as her condition deteriorated, which could have been avoided had her pain been managed more effectively".
Ms Wall noted that in March 2017, Care Alliance Limited sold the resthome to a new owner. "The two companies share no connection. HDC sought further information from the Director of Care Alliance Limited, who advised that he held no relevant information about the rest home because he no longer had possession of his laptop where the information was stored, nor was the information stored elsewhere."
That meant the HDC report had to be based on incomplete information provided by other parties.