Coroner critical of Spectrum Care after woman left unchecked for two days, found dead in bed

Ruth Finau, an intellectually disabled woman living in supported accommodation provided by Spectrum Care, was left unchecked for two days before staff discovered her dead in bed. Photo / Supplied

A young intellectually disabled woman living in supported accommodation was left unchecked for two days before staff discovered her dead in bed.

Now a coroner has found the reason for the delay in finding Ruth Kathleen Toka, also known as Ruth Finau, was because staff feared the 30-year-old might act aggressively so they left her alone, rather than risk waking her when they saw her lying on her bed.

Coroner Tania Tetitaha is critical of Spectrum Care and the standards of care it provided Finau, who was living in a small flat in South Auckland when she died from sudden unexpected death in epilepsy in July 2021.

“Due to fears of aggressive behaviour, staff also allowed Ms Finau to remain in her room unchecked for two days. Given she had epilepsy and was known to be at times medically non-compliant, regular physical checks upon her welfare should have been undertaken,” she said in recently released findings.

Finau lived in the Manurewa flat with Spectrum Care staff providing cooking and cleaning support. Every afternoon staff would go to the flat and ask if she wanted them to cook dinner. She did her own dishes and kept her room tidy with some support from staff.

She liked her independence, making her own breakfast and lunch, doing her own food shopping, attending church and cultural events and catching public transport to get around the community. She visited her family once a week and enjoyed singing and watching You Tube videos of people auditioning for musical talent shows.

But, Finau had a history of lashing out, with seven reported incidents of verbal and physical aggression. Coroner Tetitaha found it was fear of that aggressive behaviour that allowed Finau to remain unchecked in her room for two days.

Finau’s older brother Jonathan Toka told NZME his sister could be aggressive, but only when she felt she was being ignored or treated badly.

He described his younger sister’s death as “shocking” and said he felt Spectrum Care had tried to fob off the family, initially telling them his sister had died of natural causes and Spectrum wasn’t at fault.

Toka said the coroner’s report had completely contradicted this, with tests showing there was no, or very low levels of the anti-convulsant medication his sister needed to take, found in her system when she died.

A Spectrum Care spokesperson told NZME her passing was a tragedy for her family and those who supported her and changes have since been made, including providing better oversight of clients who are responsible for managing their own medication.

Before her death, Finau had given staff the food she wanted cooked for dinner.

It was delivered to her room and later she went to thank the staff member for cooking the meal, before returning to her room.

Coroner Tania Tetitaha was critical of Spectrum Care and the standards of care it provided Ruth Finau. Photo / Tania Whyte

The next day - July 19 - a staff member went to ask Finau what she wanted for dinner. Music was playing and she was lying on her bed. Due to fears of her aggressive behaviour the staff member decided not to wake her. No one heard from Finau that evening or during the night.

The next day a staff member again checked on Finau and noticed she was lying in the same position as the day before. She shook her but Finau was unresponsive. Emergency services were called and a paramedic confirmed she was dead.

Along with her intellectual disability and epilepsy, Finau also had diabetes.

Staff had “negotiated” with Finau so she had a week’s worth of blister-packed medications she self-administered.

Every day staff reminded her to take her drugs. If she was in a good mood she took them, but if angry, Finau would often refuse, even hiding the blister pack so staff couldn’t check it.

Sometimes she forgot to take her drugs altogether.

A post-mortem found Finau was not taking her anti-convulsant medication at the time of her death, with no evidence of one of the drugs in her system and low levels of another.

In her findings, Coroner Tetitaha was critical of Spectrum Care and the standards of care it provided, noting there was no formal monitoring to ensure Finau was taking her medication.

“The evidence indicates staff were reluctant to actively monitor Ms Finau due to aggressive behaviour.”

It recommended Spectrum undertake its own audit of the case.

Spectrum’s communication and marketing manager Justin Walsh told NZME Finau was strongly committed to managing all aspects of her life, including her medications.

But in the absence of a compulsory treatment order, no one can be forced to take their medication, he said.

Walsh said as a result of the tragic event, Spectrum initiated an independent review which recommended a formal assessment process to document those clients who took their own medication, along with agreements and monitoring requirements.

These were now overseen and reported on monthly.

That review also found staff had a good level of information about Finau’s support needs and were well supported by training and specialised staff within the organisation.

The coroner’s five recommendations included defining the minimum requirements for ‘oversight’ of people receiving around the clock care, ensuring formal procedures are in place for people managing their own medicine, undertaking cultural reviews of all clients, having plans in place so staff can leave their shift following a serious incident and establishing procedures for maintaining communication with families who are hard to contact.

The coroner also referred the case to the Health and Disability Commissioner, noting there was a public interest in investigating the death.

The Commission confirmed to NZME it had received the referral and the case was currently under assessment.

Catherine Hutton is an Open Justice reporter, based in Wellington. She has worked as a journalist for 20 years, including at the Waikato Times and RNZ. Most recently she was working as a media advisor at the Ministry of Justice.