Blog, aged care, depression

Nursing home death ignored

How a man ended up dead from an insulin overdose only a month after being admitted to a nursing home

And five years later no one had been held responsible

While mainstream media publishes stories of mistreatment in aged care sector, the truth is only a small number of care facilities are bad.

The problem is that bureaucrats keep the places where errors regularly occur hidden from public scrutiny. And politicians are too lazy to tackle the companies that run private homes and force them to publish statistics about complaints.

This leaves finding a nursing home placement for your elderly relatives a hit and miss affair.

As with hospitals, secrets about errors prevents competition among health care providers, closure of bad ones and raised standards across the general sector.

Secrecy also ensures that bad nursing staff are rarely deregistered. And facilities that are repeat offenders are virtually never shut down.

This leaves the general public at unnecessary risk. It also drags down the reputation of good homes and good nurses.

Everyone would benefit from transparency, tax payers, clinical staff and patients.

A true story

An 70-year-old man called Carl was living alone and was recovering from a slow healing leg ulcer. Apart from having insulin-dependent diabetes, Carl was medically stable.

He was independent and looked after himself well. However, Carl was lonely. After a discussion with his family, he agreed to move into a low-level nursing home, called a Hostel.

The hostel looked glamorous. It was like a hotel, with large, elegant rooms and plush fittings.

As soon as he was admitted to the nursing home, Carl’s normal long-acting insulin was changed to a different, short-acting insulin. His General Practitioner was not advised of this change. Neither was Carl’s family.

Carl’s blood sugars quickly became unstable. However, his new insulin regime was not reviewed by the nursing home doctor.

The nursing home staff also did not start to take Carl’s blood sugars on a more regular basis. When Carl’s daughter came to see him, she was concerned to hear that his medications had been changed and his sugars had become unstable without the family being advised.

She started complained to nursing staff about her father’s care. No clear explanation or apology was given.

A month after he had admitted to the hostel, Carl’s daughter happened to come and visit when he nurse was changing his leg dressing. She was shocked to see how badly her father’s wound had deteriorated.

The wound had been stable for months. Now it was infected and deteriorating substantially. Carl’s daughter was extremely upset.

She announced that she would be taking her father into the hospital emergency department the next day for a formal review.

“You could be in a lot of trouble” she told the nurse. “I’m going to write a formal complaint about this”.

The next time the daughter had contact with the nursing home was early the next morning. Staff rang her to say Carl was “unwell”.

“What’s wrong” she asked, shocked. “His blood sugar is low, 1.5. We have rung the doctor.”

It turned out that Carl had been taken ill that evening and been put to bed. Night staff checked his blood sugar when they came on shift and found that it was very low. He also felt sweaty.

Staff also discovered that Carl had lost control of his bladder. They changed his pyjamas and his sheets. The nursing home doctor was rung.

The nursing home doctor told the nurse to give Carl a sandwich to eat and some juice to drink. When the nurse was free, she took a sandwich down to Carl’s room.

By now Carl was confused and calling out. The nurse told a care attendant to make sure Carl got the sandwich when he woke up.

Early in the morning the nurse rechecked Carl’s blood sugar and found it was 1.5. Despite the fact that Carl had an oral sugar paste called glycogen on his drug chart for emergencies this treatment was not given to him.

Despite the fact that the normal nursing home protocol was to call an ambulance if a resident’s blood sugar was below 2, the nurse did not do this. She rang the doctor instead.

The nursing home doctor suggested giving Carl some jelly beans. The doctor did not call back to check on Carl’s progress.

The night nurses went in to give Carl a handful of jelly beans. By this time Carl was quiet. The jelly beans were not given. His daughter was rung.

After nursing handover at 7am the night nurse went home. The morning staff went to check the patients.

They found Carl dead.

It was six hours after the doctor had been rung. His blood sugar had not been checked for four hours.

Relatives complaints achieved nothing

Carl’s sister fought furiously to file complaints against the nursing home. However the home kept denying any problems had occurred.

When she finally got her father’s  drug charts and nursing notes under a Freedom of Information order, his daughter noticed that a different insulin had been given from the one written up on the the drug chart.

Carl’s blood sugars had been done very irregularly. The nursing home still refused to accept that a problem had occurred.

The daughter then took the case the Health Department. Subsequently a number of nurses resigned from this particular home. The health department simply advised Carl’s daughter that they had no authority to investigate staff who had left a nursing home and gone to work somewhere else.

Carl’s daughter then took her complaint to the Department of Aged Care. They took over a year to investigate. At the end of two years, they announced that they were ‘very sorry’ but there was ‘nothing they could do’.

Carl’s daughter then spent two years trying to get a legal firm to take on the case. They finally declined.

After five years of diligent and persistent complaints, no one was every held account for Carl’s death.

Wikihospitals 2014

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