Oceania rest home and nurses at fault after man fell in Tokoroa respite care and later died

Waikato's Victoria Place Rest Home and Hospital has come to the attention of the Aged Care Commissioner after a man died two weeks after a fall at the facility while in respite care. Photo / Google Maps

The family of an elderly man who died following a fall at a rest home says they are struggling to find a way to live with the loss of their “king of the mountain” in what they said was the worst possible way to die.

The man, in his 80s, fell on the first night he was admitted in 2019 for a short period of respite care at Victoria Place Rest Home and Hospital in south Waikato, which Oceania Care Company Limited owns.

He died two weeks later after he was rushed to hospital when the family insisted an ambulance be called.

“As a family, we have suffered a lot over the past four and a half years, blaming ourselves, over and over imagining the shock, fear and pain that dad suffered in those dark lonely hours,” his daughter told NZME.

In a report released this week, the Aged Care Commissioner said following the man’s fall, hospital staff did not adequately respond to his deteriorating condition.

Carolyn Cooper, whose role involved acting as part of the Office of the Health and Disability Commissioner, has found Oceania Care Company Ltd breached the Code of Health and Disability Services Consumers’ Rights for respite care provided to a resident.

The man had various health challenges, including Parkinson’s disease, and he was unsteady on his feet. He was also partially blind and hard of hearing.

Despite this, he was still very “with it”, intelligent, stoic and a gentleman, his daughter said.

He was usually cared for at home, but had gone into respite care for five days after his wife had consulted with the rest of the family and then reluctantly made the decision he be placed in respite care, for her wellbeing.

The family told NZME they now feel he “may have been safer had he been left home alone”. They said the nursing staff not only failed to keep him safe but, after he fell, they failed to get him the urgent, life-saving medical he needed for another two days.

According to the report, the man suffered an unwitnessed fall on his first night there, but no assessments were undertaken, and documentation was incomplete.

When his wife pointed out bruising on his elbows and forehead, as well as graze marks on his feet caused by carpeting, a nurse replied: “We don’t know that he has fallen. He could have just bumped into a doorway.”

Three days later, his wife found him curled up in bed in a fetal position using the wall as a support, resting his head awkwardly, and still in his pyjamas.

An ambulance was called at the family’s insistence and he was admitted to hospital, where scans indicated he had suffered new strokes.

The family of an elderly man who died two weeks after a fall at a rest home say he died in 'the worst possible way'. Photo / 123RF

The man’s health continued to decline, and he died two weeks later.

His daughter told NZME the “wonderful team” at Tokoroa Hospital did their best, but her father was eventually rushed by ambulance to Waikato Hospital, where staff eased his distress and made him comfortable in his final hours.

“On behalf of my mother and my family, I want to thank the people who tried to save my dad and honour his one wish, which was simply to be able to die at home,” she said.

Cooper found a registered nurse at the rest home hospital failed to provide services with reasonable care and skill, and needed to “take responsibility for her failures and the failures of several of her staff to provide appropriate care to the man”.

She also made adverse comments about two other registered nurses who provided care for the man after his fall, but no post-fall assessment or neurological observations were carried out and there was minimal follow-up monitoring concerning the man’s shortness of breath.

Oceania said it “deeply regretted” the events outlined in the report and acknowledged the impact the man’s death has had on his family.

It also apologised for the fact he did not receive the expected standard of care while he was at the facility and acknowledged the man’s clinical records did not meet its standards of clinical practice.

Director of Clinical and Care Services, Shirley Ross, said in a statement provided to NZME that Oceania had “carefully listened to, and implemented”, all of the recommendations outlined in the commissioner’s findings, including that it had conducted an independent audit at Victoria Place Care Centre to establish what happened.

“The results confirm that this was an independent incident and not a reflection of the wider culture,” Ross said.

She said the staff directly involved in this case, who were still employed with Oceania, had received additional training to ensure that all residents were provided with services of the highest possible standard.

The report followed one in 2022 that found the same company fell well short of acceptable standards in several areas, after a woman died within a day of moving into one of its rest homes.

That report by the then-Deputy Health and Disability Commissioner found the failures were linked to nursing staff failing to follow correct procedures, in a timeframe of less than 24 hours.

Cooper also commented this week about the lack of respect shown to the man and his whānau by Oceania employees, including that they were dismissive of injuries post-fall, disregarded a doctor’s letter presented by the man’s wife and only called an ambulance after the man’s daughter-in-law threatened to drive him to the hospital herself.

“Although some of these incidents are disputed and, if they occurred, could be seen to be the actions of individual staff, my view is that management should set a positive culture with residents’ wellbeing at the centre, and Oceania failed to do so,” Cooper said.

She made several recommendations for Oceania and the three registered nurses in her report, including that the staff involved in the man’s care each undertake training on fall management, communication with consumers, and record-keeping.

It was also recommended that they formally apologise to the man’s whānau for the failures in care.

His daughter said it was unlikely an apology would fix what happened.

“We just hope this decision helps at least one family to avoid what happened to my dad, and to us.”

Age Concern NZ said the decision reinforced the importance of raising concerns with an aged care provider if people were worried.

Chief executive Karen Billings-Jensen said she understood it was hard when families felt “brushed off”, which was partly why the Aged Care Commissioner role was set up.

She said each facility should have a complaints process in place, and if people weren’t satisfied with the response, then the formal complaints process through the Health and Disability Commissioner was the next step.

Billings-Jensen stressed most aged care facilities worked very well and were safe for those in their care.

Tracy Neal is a Nelson-based Open Justice reporter at NZME. She was previously RNZ’s regional reporter in Nelson-Marlborough and has covered general news, including court and local government for the Nelson Mail.