Dementia patient lost 10kg after hip fracture, HDC faults care home, orders apology

As a daughter hugged her dying father, she whispered, “I’m so sorry, Dad, it wasn’t meant to be this way”.

In a moment piercing the fog of advanced dementia, he smiled and replied, “I know”.

Speaking to the Herald this month, the daughter said: “Honestly, if my husband hadn’t been there I probably would have thought I’d imagined that. But I didn’t imagine it, it was real.”

The father died in early 2022 in the hospital wing of Kumeū Village Aged Care, 51 days after entering the Memory Assist Unit under his own steam.

His two daughters were shocked by the treatment their dad received during his stay. After his death, they complained first to the Waitematā District Health Board (WDHB) and then, hoping for greater accountability, the Health and Disability Commissioner (HDC).

A redacted version of the HDC report, published today, found Kumeū Village Aged Care breached the father’s rights and failed to provide services with reasonable care and skill. The report also made adverse comments about care provided by a general practitioner.

His daughters, who do not want to be named, said the findings confirm what they suspected after his death. But four and a half years on, they feel the report is a weak outcome, denying them real accountability.

A hip fracture, then decline

The man – tall, solid, a former athlete – moved into Kumeū Village’s dementia unit in November 2021.

The day her father moved to the complex, one daughter sat beside her mother and watched him peel pith off a banana and place it on a cracker.

“You’re not going to eat that, are you?” the mother said.

“He just laughed and smiled. He didn’t know that he’d put pith on the top, but he ate all of those crackers and a cup of tea and a piece of baking ... and thoroughly enjoyed it.”

Thirty-six hours after the father was left in Kumeū Village’s care, the family received a call saying he’d fallen, fractured his hip and been taken to North Shore Hospital for surgery.

Surgery and general anaesthetic took a toll, a daughter said.

He returned to Kumeū Village six days later and was admitted to the hospital unit on new medications, including a diuretic for fluid overload and a sedative for agitation.

What followed, the HDC found, was a series of missed reviews and undocumented decisions.

Despite a hospital discharge instruction to review his diuretic dose within one to two weeks, no structured review took place, the commissioner found.

Staff did not weigh the father after his discharge from North Shore Hospital until his family raised concerns over his apparent rapid decline.

When weighed, he had lost 10kg and was significantly dehydrated.

He was not given regular pain relief despite a standing prescription for paracetamol.

A pressure-relieving air mattress, identified as needed within days of his return, was never confirmed as provided.

“He changed completely,” one daughter said.

“He didn’t smile. You got the odd twinkle ... but he was struggling to function on any level.”

They believe their father was likely in pain or discomfort.

“He didn’t know how to communicate, ‘I’m hurting, I’m sore’. They clearly didn’t see Dad, they didn’t see the wincing that we saw – they didn’t see anything.”

Commissioner Erin James found Kumeū Village Aged Care breached the Code of Health and Disability Services Consumers’ Rights – specifically the right to services provided with reasonable care and skill.

She was also critical of the GP, who cannot be named, for the absence of a structured plan to review the diuretic and failing to document his reasons for prescribing antibiotics.

Kumeū Village Rest Home offers rest home, hospital and dementia-level care. Photo / Michael Craig

Questioning the reports

A month after his death, the family met with Kumeū Village staff and the GP to raise concerns. One daughter said the GP struggled through the meeting on a laptop, searching for notes on her father.

The family took their concerns to the former Waitematā District Health Board in 2022, which found “serious deficits” in his care and ordered Kumeū Village to overhaul post-discharge, pain management and nutrition monitoring processes.

Those recommendations echo what the HDC has now ordered, including a process for assessing residents after hospital discharge, staff training on pain management and clinical assessment and reviews of food, fluid and weight monitoring, turning procedures and how care is co-ordinated.

Kumeū Village was also ordered to provide a written apology and evidence of training and process changes within three weeks of the report.

The apology misspelled the father’s surname.

“We thought that HDC would provide that far-reaching arm and accountability,” one daughter said.

After receiving the HDC report, the daughters replied in writing that the outcomes did not reflect the suffering and pain endured by their father and family.

“It is difficult to escape the conclusion that, had this same level of neglect occurred in a family residence, it would have been deemed elder abuse.

“Yet with an aged care facility, the consequences appear to amount to a published report for educational purposes, recommendations and coerced apologies.

“We are left feeling frustrated, deflated and deeply dissatisfied with the overall outcome after this incredibly lengthy process and investigation.”

Kumeū Village advertises itself as a premium facility. At the time of the man’s death, the family were paying more than $7500 a month for the room and care.

“You’re paying for a service,” one daughter said.

“It doesn’t seem right.”

Deep regrets

In a statement, Kumeū Village said it accepted the commissioner’s findings and had “taken the matters raised in the report seriously”.

“Kumeū Village deeply regrets the shortcomings identified in this report.”

The village said it had made the recommended changes, including staff training on pain management, food, fluid and weight-monitoring procedures and improved communication with residents and families.

Kumeū Village noted the events surrounding the father’s death occurred during the Covid-19 pandemic – “an exceptionally challenging period for the aged care sector”.

“This context is not raised to diminish the concerns identified by the commissioner, but Kumeū Village Aged Care believes it is relevant when considering the circumstances in which the events occurred.”

The GP declined to comment, citing privacy constraints.

Mike Scott is a senior visual journalist at the Herald. His work spans writing, photography and video and he has won numerous journalism awards, including Videographer of the Year and Best Documentary. He has worked in media for more than 25 years, producing stories across New Zealand and internationally.