DHB and rest home failed elderly stroke victim: HDC investigation

A rest home and DHB have been found to have provided substandard care to an elderly man after he suffered a stroke. Photo / 123RF

A DHB and rest home have been criticised for the care given to a stroke patient, including not warning a wife that her husband had suffered a major stroke prior to her visiting him and failing to manage the man's growing pain.

His family complained to the Health and Disability Commissioner about the care given to the man, in his 80s, by the DHB after he was admitted to hospital and transferred to a rest home following a stoke in 2017.

In her findings released today deputy Health and Disability Commissioner Rose Wall found the care provided by both providers to be in breach of the Code of Health and Disability Services Consumers' Rights.

She ruled the DHB did not review the man's worsening condition well enough, documented his care poorly, failed to escalate his care to a senior doctor and needed better after hours care and treatment available to stroke patients.

Wall also criticised the rest home's overall assessment of the man's agitation and management of his pain and the way it discussed his care with his family and GP.

The man, who also had other health issues, was admitted to hospital in 2017 with slurred speech and a facial droop as a result of transient ischemic attacks.

He then suffered a major stroke overnight while in the hospital and was transferred to a rest home the following month

.

The man's daughter complained that his family were not made aware by the DHB that he had suffered a major stroke until her mother visited him the next morning and "she literally did not recognise her husband".

The couple's daughter said the DHB showed "absolute disregard in their communication with (her mum) and made no attempt to contact any other family member".

The doctor also told the HDC that he was unable to complete his assessment of the man because of the heavy workload and because he was dealing with an emergency so the man was left unseen.

He had assumed that someone else would call for medical support - but this did not happen.

The doctors caring for the man said it was also unclear from the documentation why he was not assessed for thrombolysis after the stroke.

Two weeks later he was transferred to a rest home closer to his family and church and only two weeks after that a care plan was completed.

The rest home told the HDC it was late writing up the care plan because the man's needs and abilities were changing often.

The man's daughter also expressed her concern to learn that 12 hours prior his death they were "appalled, distraught and bewildered" to discover there was no end-of-life care plan in place.

The family said despite his health deteriorating during his last month of life, at no stage was a plan including the possibility of involving Hospice discussed with the family.

"I strongly emphasis to health providers the importance of initiating end-of-life conversations and instigating end-of-life protocols once a patient has been assessed for palliative care and prior to a patent's deterioration, to enable the person to have a voice (if able) along with their family."

Wall ordered both the DHB and rest home to apologise to the family and update and review its protocols around strokes and when end-of-life conversations should be had with families.