Tetraplegic spent 12 hours in chair with a full catheter bag and no overnight carer

A tetraplegic who cannot be left alone spent more than 12 hours in his sofa chair unable to move, suffering painful spasms with a full catheter bag after a carer failed to turn up.

The man, identified as Mr A, complained to the Health and Disability Commissioner after Healthcare NZ’s failure to provide him with a support worker in October 2021.

In his complaint, the man noted this wasn’t an isolated incident and had occurred three times in the previous week.

In a decision released today, Deputy Commissioner Rose Wall said the man, who was 51 at the time, had been tetraplegic since an accident in his early 20s.

He lived in a fully modified home. Because his family lived out of town, he was reliant on support from Healthcare NZ, contracted by ACC to provide 24-hour care and had done so for 14 years.

According to the decision, a team of eight support workers was to care for the man.

However, a support worker took leave, and her shifts were covered by another staff member, who also took leave.

Aware the shift wasn’t covered, the man phoned the service centre to ask about cover.

“The shift wasn’t filled, the agency had known about it for weeks that it needed covering. I had rung earlier that week to make sure it was filled and that someone was coming. They told me a carer named [...] would be working and not to worry,” the decision said.

Deputy Health and Disability Commissioner Rose Wall. Photo / Lance Lawson

In its response, Healthcare NZ said it had limited staffing due to Covid restrictions and mandates. It offered the man a relatively inexperienced support worker who had recently joined the team, but he refused.

Efforts to find cover continued, with the task passed to the After-Hours Team Leader. Meanwhile, the support worker who’d cared for the man during the day agreed to stay for a couple of extra hours in the hope of finding someone to replace her.

She told the HDC she received a phone call from Auckland saying she could leave at 7pm and they were finding another person to look after the man.

The following morning, a support worker arrived to find the man had been left overnight without support and reported this to Healthcare NZ’s Service Centre.

While he was alone, the man was unable to turn or move to receive pressure relief to prevent pressure injuries, and he experienced painful spasms throughout the night, which caused him to overheat.

The spasms continued for the remainder of the week. In addition, the man’s catheter bag was not emptied for more than 13 hours.

According to the decision, the HDC’s investigation identified several inconsistencies between Healthcare NZ’s responses and the statement from the support worker who stayed until 7pm, the man’s complaint and the statement by the After Hours Team Leader.

Wall found Healthcare NZ had a responsibility to provide continuous care and quality service.

She said that as a physically incapacitated and vulnerable consumer, the man could not be left alone and relied on 24-hour care from Healthcare NZ.

“Given the number of staff and different teams involved in the management of Mr A’s roster and the provision of his cares, I am holding HealthCare NZ responsible for the systemic failures that led to Mr A being left unattended for an extended period of time and at risk of harm.

“The shortcomings in the care provided to Mr A included ineffective communication of critical information between staff and a lack of accountability by the staff responsible for planning Mr A’s roster”.

Changes made since the event

Healthcare NZ apologised to the man and said it updated its client management system to reduce the possibility of uncovered shifts.

The handover template sent to the after-hours team was also updated to highlight work that needs to be completed to ensure all shifts are covered.

Efforts have been made with other providers to increase the pool of appropriately trained staff available, and more relief support workers have been introduced to the man so he could build rapport with more people.

The deputy commissioner said the changes were appropriate and showed Healthcare NZ had taken responsibility

When contacted in April last year, the man said the service provided by Healthcare NZ had improved since his complaint.

He confirmed he hadn’t been left unsupported overnight, although occasionally he was left alone for a couple of hours.

The man also said some staff members were not trained to use hoists, meaning his personal care needs were not being met.

He also mentioned that his requests to replace those staff members with those trained to use hoists had not been addressed.

Among her recommendations, Wall said Healthcare NZ was to report back on changes it had made since 2023. It was also to provide an update on internal changes within six months of its report.

Catherine Hutton is an Open Justice reporter, based in Wellington. She has worked as a journalist at the Waikato Times and RNZ. Most recently, she worked as a media adviser at the Ministry of Justice.