Rehabilitation care provider breaches Code in its care of vulnerable resident - 20HDC01681

The Deputy Health and Disability Commissioner has found Bupa Whangarei Rehabilitation Pou Oranga (BPO) breached the Code of Health and Disability Services Consumers’ Rights (the Code) for failing to provide services with reasonable care and skill (Right 4 (1)) to one of its residents.

Ms Rose Wall also found BPO failed to facilitate the fair, simple, speedy and efficient resolution of a complaint (Right 10 (3)) made on behalf of the resident by his mother. At the time of these events the man lived independently in a unit at BPO, but required support from BPO with many activities on a daily basis.

The breaches stem from the care BPO provided to the man in 2020. The man lives with spina bifida and paralysis of his lower body, and uses a wheelchair to mobilise. He has an extensive medical history, which includes a number of complex urological issues. This has led to the long-term use of an indwelling catheter. The man was prone to recurrent urinary tract infections.

The complaint concerned a failure by BPO staff to take appropriate action for stage three pressure injuries leading to the man’s hospitalisation with sepsis (a medical emergency which can lead to tissue damage, organ failure and death), a serious pressure injury on the man’s foot and his development of purple bag syndrome (where urine in a catheter bag turns purple, potentially indicating a urinary tract infection UTI). Ms Wall was critical of BPO for the following reasons:

• Repeatedly failing to put in place short term care plans for managing the man’s pressure injuries
• Failing to monitor and respond to the man’s risk of a UTI
• Failing to identify that the man’s urinary output should have been monitored
• Not ensuring the man had three monthly GP reviews or making his GP aware of his documented symptoms

She was also critical of the way the mother’s complaint was managed, saying that in its handling of the complaint, BPO failed to follow its own guidance to, "enable the identification and management of complaints using a customer-focused process that is fair, accessible, efficient, confidental and achieves resolution."

"As such, while [the man’s mother] received verbal and written responses to her complaint, I consider that these responses were insufficient, particularly given the complexity of the matters complained about."

Ms Wall has recommended that Bupa (on behalf of BPO) formally apologise to the man for the care issues he experienced, and to his mother for BPO’s management of her complaint. She has also recommended Bupa provide a full summary of a clinical file review of the man’s care to his mother.

Bupa has advised HDC that it has made several changes in response to the woman’s complaint about her son’s care. This includes specific additional training in complaints management, medication prescribing and administration, wound management, and continence management.