KEY POINTS:
Geriatric hospital resident Leonard Stevenson was fed with a tube because he needed to put on weight. Instead, he was inadvertently starved, losing 16kg in nine months.
He became so thin and developed such bad pressure sores - linked to poor nutrition - that on admission to Palmerston North Hospital he was said to look like a victim of a Nazi death camp. He died in 2002 in his 80s.
In a decision issued yesterday, the Health Practitioners Disciplinary Tribunal found the head nurse from Mr Stevenson's unidentified aged-care facility guilty of professional misconduct for not consulting a doctor or dietitian over changes to his feeding and not reviewing it.
The tribunal found her not guilty of instigating the changes in September 2000.
Mr Stevenson had been in institutional care since 1995. He had a head injury, developed epilepsy and had a stroke, becoming paralysed on one side. In February 2000, he had a heart attack and was admitted to Palmerston North Hospital.
He was found to have been inhaling food and had a limited swallowing reflex, so it was decided to feed him through a tube.
At one stage, he received 2000 millilitres a day of Jevity, a liquid food and 600ml of water, and put on weight.
In June 2000, the Jevity was cut to 1800ml a day at his aged-care facility, but by a nurse other than the nurse who faced the charge before the tribunal and has interim name suppression.
His intake was later reduced to 1500ml, still above the 1400ml he needed to be "nutritionally complete".
By October, Mr Stevenson's Jevity had been reduced further, to 1000ml, a pattern that held at his aged-care facility, except for once in June 2001.
The reductions were apparently because of stomach distension and pain. His water intake was also cut.
"Thereafter, the records chart a slow deterioration of Mr Stevenson to the time of his admission into Palmerston North Hospital in March 2002," the tribunal said. "Of particular concern ... was the evidence that upon admission to hospital, he looked like he had been in a concentration camp."
His weight had dropped to 57.3kg in February 2002 from 75.6kg in June 2000.
The tribunal said all the evidence showed that the nurse was "extremely dedicated, hard-working, caring and professional".
"The most distressing part of this case is that while the care that Mr Stevenson received seems to have been loving, there is no doubt that he was being slowly starved and probably dehydrated."
A dietitian's evidence said the nurse was "devastated" to learn of the minimum amount of Jevity needed to be nutritionally complete.
Her lawyer said the case was a travesty of errors and omissions aggravated by poor management.
The tribunal has yet to decide on a penalty.
