WorkSafe investigated the death but took no further action after finding no clear breaches of the Health and Safety at Work Act. Photo / RNZ
A WorkSafe investigation found the death of an intellectually disabled woman in a care home was preventable - but no one was prosecuted.
The resident was left unsupervised at her IDEA Services flat on Auckland’s North Shore in December 2020 and choked on leftover food.
She was rushed to hospital but died the next day.
IDEA Services notified the Ministry of Health of the 63-year-old’s death two days later and three days before Christmas, but the case was not referred to the Coroner after a GP signed the death certificate.
It is unclear whether a complaint was made to the Health and Disability Commissioner [HDC], but in the woman’s death notice her family thanked IDEA Services staff for their care of her.
The death came two years after an intellectually disabled 59-year-old man choked on uncut sausage in another IDEA Services home and died.
In that case, the Coroner referred the death to the HDC which found IDEA Services, a subsidiary of IHC, breached the Code of Health and Disability Services Consumers’ Rights by not providing the man services with reasonable care and skill.
On the night the woman choked, she was one of three residents living in a block of three units operated by IDEA Services, according to a heavily redacted copy of the WorkSafe investigation report released to NZME under the Official Information Act.
The report said three regular support workers were available to be rostered to help the residents.
However, on that night there were two support workers rostered. One was scheduled to take one of the residents to the Christmas lights in Ponsonby’s Franklin Street between 6pm and 10.30pm, leaving the other alone to look after two residents.
The support worker looking after the woman who later died, cut up her roast dinner and watched her eat it at the kitchen bench.
The resident’s care plan included that she was a known and indicated choking risk. This was because the woman would eat leftovers if it wasn’t put away in the microwave or cut up and stored in the fridge.
“After dinner [the support worker] went to the kitchen to start tidying up and, in accordance with [the resident’s] Personal Support Plan, was about to cut up a small piece of leftover meat to put away when she heard another resident scream out and call her from next door,” the WorkSafe investigator wrote in the report.
“[She] quickly put the uncut meat in the fridge and ran over as she thought it was an emergency.”
The support worker recalled being gone for four to five minutes.
“While [she] was gone, [the resident] accessed the leftover food and choked on it. She was found by [the support worker] and taken to hospital where she later passed away.”
In its internal review released to WorkSafe in April 2021, IDEA Services said it had clear policies and procedures for managing choking risks and on the day in question, “it appears the support worker did not follow IDEA’s expectations, of dealing with the leftover food before being called away to support another person”.
“As a result, [the client] was able to access the food and eat it unsupervised, which did not meet her support plan and risk management requirements.”
Under further questioning from WorkSafe, IDEA Services said the plan for dealing with an unexpected emergency involving the other two residents was that support workers were able to phone other support staff within the units.
But this was not possible that night as the other worker was out.
IDEA Services’ expectations were that the lone support worker should have taken the resident she was supervising with her to the emergency, or that she should have discussed with the woman she was being left alone for a short period of time as was usually the case.
The WorkSafe investigator said there was no plan for emergency situations for a lone support worker to “safely manage the three flats in unexpected circumstances like these”.
“[The worker] was put in a difficult situation. She was called away in a potential emergency to assist a neighbouring resident,” the investigator wrote.
“She made an ‘on the spot’ decision in ‘good faith’ to attend to the call for help, as she thought [the woman] had finished her dinner and was attending to laundry.
“By only having one rostered worker on to cover three users (one requiring meal supervision) IDEA placed [the worker] in a ‘no-win’ situation in the event of an emergency or unforeseen event.
“This situation was unexpected and [the worker] thought she was needed urgently. IDEA did not have a plan for emergency callouts during [the woman’s] mealtime supervision.”
This placed the worker in the difficult situation of having to make a judgment call whether to attend a call for help or not, the investigator said.
“Had there been sufficient staffing levels to safely monitor the three residents at mealtimes (rather than a 1/3 ratio) this would not have been an issue and this situation could have been prevented.”
WorkSafe said the only failure potentially identified was that the worker did not follow procedure by immediately cutting up and placing covered leftovers in the neighbouring resident’s fridge.
“However, the circumstances around this are unusual and would not warrant a prosecution against the worker. [The woman] was able to be left alone for periods of time (30 to 60 minutes) and had free access during this time to food in her own fridge.”
WorkSafe said there had been no clear breaches of the Health and Safety at Work Act identified against IDEA to support a prosecution.
No further action was recommended and WorkSafe signed off the report in August last year.
The HDC confirmed it had 10 open complaints involving IDEA Services, but none that involved a death or choking.
Natalie Akoorie is the Open Justice deputy editor, based in Waikato and covering crime and justice nationally. Natalie first joined the Herald in 2011 and has been a journalist in New Zealand and overseas for 27 years, recently covering health, social issues, local government, and the regions.
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