The failure of rest home staff to check on an elderly woman the night she disappeared meant it took 12 hours to realise she was missing, the coroner says.
Helen Maree Dale Wilkins, 85, was reported missing from the Leigh Road Cottage rest home, north of Auckland, in November 2017.
Despite extensive searches, she has never been found, and the matter was referred to the coroner in September 2018.
In her just-released findings, Coroner Debra Bell has concluded Wilkins died.
Bell ruled out suicide and said the police had no leads of a substantial nature to support any foul play.
"It remains a possibility that she left the facility and became confused and unable to return," Bell said.
The coroner was provided with a report by the Waitematā District Health Board, from the rest home, about Wilkins' disappearance.
In it, it said it took staff more than 12 hours to realise Wilkins was missing, as company policy and procedure was not followed, which included checking on residents every two hours during the night.
The time Wilkins went missing could not be determined as staff could only be certain they saw Wilkins at dinner and they did not know if she was in the building at 7pm when it was locked, the report said.
There were also previous incidents of a similar nature at the rest home that were not reported to the DHB. One included a resident going missing for about six hours after they were let out by a visitor.
Bell said a number of changes have been implemented at Leigh Road Cottage since Wilkins' disappearance, including:
- Hourly checks from 7pm-6am, in which staff physically check residents and sign a daily checking record.
- Staff training to address safety issues at night.
- Implementation of a 10-minute general handover, then a designated wing handover regarding each resident.
- Improved locks and gates, and the installation of a camera.
The DHB identified gaps in the rest home's investigation and found a number of areas that required action.
- Reviewing and updating policies and procedures relating to staff safety.
- Reviewing process and documentation for how residents' whereabouts is routinely checked, including frequency.
- A review of staff competency, relating to why they did not follow procedure.
The coroner said the DHB was satisfied Leigh Road Cottage had met all these requirements.
Bell said she hoped these changes would reduce the chances of further deaths occurring in similar circumstances.