'Human error' left man without care for months

The deputy health and disability commissioner (HDC) has found a man was left without care for four months after a "human error" from care provider Nurse Maude.

Nurse Maude had been providing care to a man residing in an independent living unit at a care home between 2018 and 2020. The man was diabetic and had a catheter.

Nurse Maude had been doing daily checks to help the man with his insulin, but had reduced those checks to only during his scheduled catheter care visits.

However, the HDC found further catheter care visits were not scheduled, and the man's subsequent request for a new catheter bag was not followed up.

Nurse Maude told the HDC it was a result of "human error".

The man was taken to a hospital emergency department after not receiving catheter care for four months. He was found to be suffering from an urinary tract infection, had life-threatening complications from an extended period of high blood sugar due to missed insulin injections and some cognitive decline was also noted.

The family believed the failures by Nurse Maude contributed to the decline of his health, and he required rest home level care after he was discharged.

Deputy Health and Disability Commissioner Dr Vanessa Caldwell recommended Nurse Maude formally apologise to the man's family, develop a system to manage clients needing catheter care and provide the HDC with three-monthly audits of its adherence to a district nursing discharge procedure from 2022 to the present.

Caldwell was also critical of the care home company where the man was residing, which could not account for a three-hour delay between the man using his emergency call bell and being attended by a caregiver to an ambulance being called.

She recommended the care home company provide education and staff training on clinical documentation, and audit adherence to its policy on responses to call bells and emergency procedures.