17 Jul 2023

'Lax practice' at facility led to disabled man's death, watchdog says

3:39 pm on 17 July 2023
Iv Drip in hospital corridor

The man died in hospital two days after he was found unconscious (file image). Photo: 123rf

A man with cerebral palsy and an intellectual disability died after support workers failed to cut up his food, despite knowing he was at risk of choking, a watchdog has found.

He had lived at the IDEA Services residential facility for more than a decade.

In a just-released Health and Disability Commissioner report, deputy commissioner Rose Wall found the lax practice of the company, and an individual support worker, led to the man's death in 2018.

She said staff were meant to be present when he was eating and remind him to chew his food, but on this day he left the dinner table alone. He was found unconscious within minutes by a support worker, but died in hospital two days later.

His death was preventable, Wall said, noting the man's support plans described his choking risk and how it was to be managed.

She found IDEA Services had failed to make sure its staff adhered to the man's support plans, ensure staff training was up-to-date, and have adequate staffing levels.

140814. Photo supplied. Health and Disability Commision. Rose Wall, Disability Deputy Commissioner

Deputy Health and Disability Commissioner Rose Wall. Photo: Supplied

"IDEA Services failed in its duty to manage the resident's risks, keep him safe and provide an appropriate standard of care.

"Although IDEA Services had a system in place for managing risk, this did not translate into practice. It is disappointing that a lax practice had been allowed to develop at the house, with a culture of complacency in relation to the management of risk."

Wall said the support worker who was looking after the man should have cleared his airways before performing CPR.

"By not adhering to the resident's support plan to mitigate his risk of choking, and not attempting to clear his throat before commencing CPR, [the support worker] did not provide services to the resident with reasonable care and skill."

She was also concerned that another worker had left their shift early, before the meal was served, but did not find they had breached the Code of Health and Disability Services Consumers' Rights.

IDEA Services had formally apologised to the man's family and improved staff training, Wall said.

Both support workers were remorseful and had written apologies to the man's family.

The deputy commissioner noted the changes but recommended the case was used as a reminder of choking risks and to highlight the importance of following individual support plans.

IDEA Services should also ensure staff have the express permission of their manager to leave a shift early, she said.

The company was to report back to the Health and Disability Commissioner within three months.

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