Treatment insufficient

Dunblane and hospital criticised in commissioner’s report.

Dunblane and hospital criticised in commissioner’s report.

Dunblane Rest Home.
Gisborne Hospital. File picture
HAPPIER TIMES: This picture of the late Alison Jackson, 84, was taken one month before her fall at Dunblane Rest Home and Village. Daughter Leigh Morrow believes the fall ultimately led to her mother’s death. Picture supplied

The daughter of a Dunblane Rest Home resident injured in a fall at the facility, believes her 84-year-old mother would be alive today if the rest home had provided timely physiotherapy.

In a letter to the late Alison Jackson’s daughter Leigh Morrow, deputy Health and Disability commissioner (HDC) Rose Hall agrees Dunblane should have followed up with district health board Hauora Tairawhiti to ensure Mrs Jackson received treatment in good time.

“The report basically says both Dunblane and Hauora Tairawhiti were left wanting,” says Mrs Morrow.

“Dunblane accepted they were responsible for her fall and the hospital forgot to follow up on the rehabilitation.

“As a result, she lay on her back and ended up dying.

“I have no doubt if she received rehabilitation as was ordered she would be alive today.”

Mrs Jackson, who lived in Dunblane’s dementia wing, hit her head on the ground and broke her pelvis in a fall after getting out of a van at the rest home in October last year.

The accident happened after the van returned Dunblane residents to the rest home at the end of a day trip.

The driver found the usual parking space was occupied and parked in front of the home. The sole staff member accompanying the group helped residents, including Mrs Jackson, out of the van.

Unsupervised, and without the walking frame she generally relied on for mobility, Mrs Jackson took a few steps, stumbled on a low kerb and fell.

“Upon review by a registered nurse, it was decided your mother be immediately transferred to the hospital as she had sustained a head injury and was in pain,” wrote the deputy HDC in an August 15 report.

Because she was immobile due to a fractured pelvis, she was taken back to Dunblane at hospital-level care a week later.

In her complaint to the HDC about the treatment given to her mother, Mrs Morrow said her mother was not provided with an air mattress to prevent pressure sores until she contacted Dunblane and requested one.

In her August 15 report to Mrs Morrow, the deputy HDC said Oceania Healthcare’s clinical and quality manager Jane Watson explained that although Mrs Jackson was repositioned frequently, she could not be placed on an alternating air mattress due to extreme pain.

Aged-care giant Oceania is the owner of Dunblane Rest Home and Village.

“However, as her pain subsided, she was able to be placed on an alternating air mattress but was still bed-bound.”

Mrs Morrow also felt she had not been adequately kept up to date about her mother’s condition.

Six and half weeks after Mrs Jackson hit her head on the ground and broke her pelvis as a result of the fall, she began to get rehabilitative treatment from Hauora Tairawhiti.

Asked for clarification about the lack of follow-up on Mrs Jackson’s physiotherapy sessions, Oceania’s aged-care general manager Barbara Sangster told the HDC a referral for community assessment was sent to Hauora Tairawhiti on November 15 last year, once her mother’s pain had lessened and her overall health status had improved.

Mrs Jackson was seen by a community therapist on November 30. She was next seen by the therapist on January 18.

“However, there were no follow-up appointments provided to her as promised,” wrote the deputy HDC in her report to Mrs Morrow.

Hauora Tairawhiti’s quality and risk systems manager Amelia Brown-Smith reported that, after the initial physiotherapy, facility caregivers were given a plan to follow up for therapy in one week.

“She states that further treatment was dependent on Dunblane updating Hauora Tairawhiti on your mother’s progress and the physiotherapist did not hear from Dunblane regarding the follow-up,” the deputy HDC told Mrs Morrow.

The physiotherapist followed up herself and saw Mrs Morrow’s mother in January.

Four days after her last treatment, a doctor called Mrs Morrow to say her mother had deteriorated after developing a chest infection.

End-of-life care was started and she died in the early hours of January 28.

“Please note, the responses are basically blaming each other,” said Mrs Morrow in an email to The Gisborne Herald.

“You will note Dunblane says they ‘mobilised’ Mum almost daily but actually what that was, was using a hoist to transfer her from bed to a lay-down type chair so they could push her into the lounge during the day. That does not constitute rehabilitation, as they have attempted to imply.”

Mrs Morrow believes delays in rehabilitation for her 84-year-old mother’s broken femur ultimately killed her mother.

“She spent six unnecessary weeks lying on her back which, without doubt, was either the cause of or hugely contributed to her chest infection.”

The daughter of a Dunblane Rest Home resident injured in a fall at the facility, believes her 84-year-old mother would be alive today if the rest home had provided timely physiotherapy.

In a letter to the late Alison Jackson’s daughter Leigh Morrow, deputy Health and Disability commissioner (HDC) Rose Hall agrees Dunblane should have followed up with district health board Hauora Tairawhiti to ensure Mrs Jackson received treatment in good time.

“The report basically says both Dunblane and Hauora Tairawhiti were left wanting,” says Mrs Morrow.

“Dunblane accepted they were responsible for her fall and the hospital forgot to follow up on the rehabilitation.

“As a result, she lay on her back and ended up dying.

“I have no doubt if she received rehabilitation as was ordered she would be alive today.”

Mrs Jackson, who lived in Dunblane’s dementia wing, hit her head on the ground and broke her pelvis in a fall after getting out of a van at the rest home in October last year.

The accident happened after the van returned Dunblane residents to the rest home at the end of a day trip.

The driver found the usual parking space was occupied and parked in front of the home. The sole staff member accompanying the group helped residents, including Mrs Jackson, out of the van.

Unsupervised, and without the walking frame she generally relied on for mobility, Mrs Jackson took a few steps, stumbled on a low kerb and fell.

“Upon review by a registered nurse, it was decided your mother be immediately transferred to the hospital as she had sustained a head injury and was in pain,” wrote the deputy HDC in an August 15 report.

Because she was immobile due to a fractured pelvis, she was taken back to Dunblane at hospital-level care a week later.

In her complaint to the HDC about the treatment given to her mother, Mrs Morrow said her mother was not provided with an air mattress to prevent pressure sores until she contacted Dunblane and requested one.

In her August 15 report to Mrs Morrow, the deputy HDC said Oceania Healthcare’s clinical and quality manager Jane Watson explained that although Mrs Jackson was repositioned frequently, she could not be placed on an alternating air mattress due to extreme pain.

Aged-care giant Oceania is the owner of Dunblane Rest Home and Village.

“However, as her pain subsided, she was able to be placed on an alternating air mattress but was still bed-bound.”

Mrs Morrow also felt she had not been adequately kept up to date about her mother’s condition.

Six and half weeks after Mrs Jackson hit her head on the ground and broke her pelvis as a result of the fall, she began to get rehabilitative treatment from Hauora Tairawhiti.

Asked for clarification about the lack of follow-up on Mrs Jackson’s physiotherapy sessions, Oceania’s aged-care general manager Barbara Sangster told the HDC a referral for community assessment was sent to Hauora Tairawhiti on November 15 last year, once her mother’s pain had lessened and her overall health status had improved.

Mrs Jackson was seen by a community therapist on November 30. She was next seen by the therapist on January 18.

“However, there were no follow-up appointments provided to her as promised,” wrote the deputy HDC in her report to Mrs Morrow.

Hauora Tairawhiti’s quality and risk systems manager Amelia Brown-Smith reported that, after the initial physiotherapy, facility caregivers were given a plan to follow up for therapy in one week.

“She states that further treatment was dependent on Dunblane updating Hauora Tairawhiti on your mother’s progress and the physiotherapist did not hear from Dunblane regarding the follow-up,” the deputy HDC told Mrs Morrow.

The physiotherapist followed up herself and saw Mrs Morrow’s mother in January.

Four days after her last treatment, a doctor called Mrs Morrow to say her mother had deteriorated after developing a chest infection.

End-of-life care was started and she died in the early hours of January 28.

“Please note, the responses are basically blaming each other,” said Mrs Morrow in an email to The Gisborne Herald.

“You will note Dunblane says they ‘mobilised’ Mum almost daily but actually what that was, was using a hoist to transfer her from bed to a lay-down type chair so they could push her into the lounge during the day. That does not constitute rehabilitation, as they have attempted to imply.”

Mrs Morrow believes delays in rehabilitation for her 84-year-old mother’s broken femur ultimately killed her mother.

“She spent six unnecessary weeks lying on her back which, without doubt, was either the cause of or hugely contributed to her chest infection.”

Poor communication hindered care

Poor communication contributed to the lack of a follow-up physiotherapy appointment for Dunblane Rest Home and Village resident Alison Jackson, notes deputy Health and Disability commissioner (HDC) Rose Hall in a report to Mrs Jackson’s daughter, Leigh Morrow.

“I agree with you that Dunblane should have followed-up with Hauora Tairawhiti to ensure that your mother received timely physiotherapy treatment and that your inquiries should have prompted them to do this earlier.

“I remain confident that your complaint will improve services for residents of Dunblane, and other Oceania residents across the country, in the future.”

The deputy HDC recommended the rest home’s owner, Oceania Healthcare, conduct an audit of consumers’ care plans at Dunblane from the last six months to ensure service improvement.

“I remain confident that your complaint will improve services for residents of Dunblane, and other Oceania residents across the country, in the future.”

Oceania has implemented measures that include prevention of pedestrian access to the footpath through the use of pot plants.

Two staff will now help residents in and out of the van and van trips from the dementia unit will be made from the entrance closest to the unit.

Hauora Tairawhiti has adjusted its processes to ensure it will follow up on the provision of physiotherapy services, says the deputy HDC in her report to Mrs Morrow.

In a letter to HDC’s complaints assessment team, Hauora Tairawhiti quality and risk systems manager Amelia Brown-Smith says, “We are very disappointed that there was a breakdown in communication and we did not follow up on Mrs Jackson’s progress.

“We have adjusted our processes to ensure that this does not happen again.”

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