Nelson Marlborough DHB And Springlands Lifestyle Village Breached The Code In Management Of Man’s Wound Care

Aged Care Commissioner, Carolyn Cooper, has found Springlands Lifestyle Village (Springlands) and Nelson Marlborough District Health Board (DHB) (now Te Whatu Ora Nelson Marlborough) breached the Code of Health & Disability Services Consumer’s Rights (the Code) in relation to a man’s wound care.

The man, in his eighties at the time, was transferred between Wairau Hospital (Nelson Marlborough DHB) and Springlands three times, following a hip fracture, suspected urinary tract infection and sepsis of unknown origin.

While at Wairau Hospital, nursing staff commenced wound management charts and care plans for the man, concerning three abrasions on his body and a pressure injury on his heel. However, the pressure injury was not documented correctly and there were omissions in the wound chart. There was also a delay in providing the man with a pressure relieving mattress.

Following the man’s initial discharge back to Springlands, there was a plan for Springlands nurses to continue wound cares and monitor for infection. However, no wound care plan was completed for the pressure injury. Despite Wairau Hospital’s transfer note stating the high need for a pressure-relieving mattress due to the existing pressure area, this was not implemented by Springlands staff.

In her report, Ms Cooper found Nelson Marlborough DHB did not have sufficient policies and procedures in place to adequately support staff to identify, assess and manage pressure injuries.

"Although wound management charts were completed during the man’s first admission at Wairau Hospital, there is a concerning absence of comprehensive wound chart entries for his later admission when the pressure injury was still present," said Ms Cooper.

Ms Cooper found Nelson Marlborough DHB breached Right 4(1) of the Code for failing to provide the man with an appropriate standard of care, and for the lack of adequate guidance in place for its staff regarding the management of pressure injuries.

Ms Cooper also found Springlands did not appropriately manage or care for the man’s pressure injury after he was first discharged from Wairau Hospital and there is no evidence they completed the appropriate care plan or cares for the pressure injury.

Ms Cooper says, "I am particularly critical that even when a healthcare assistant recorded the man had complained of sore heels, it appears that no appropriate care was commenced ."

Ms Cooper found that Springlands breached Right 4(1) of the Code for its failure to provide the man with an appropriate standard of care.

Ms Cooper recommended that both Te Whatu Ora and Springlands:

- Provide the family with a written apology for their respective breaches of the Code.

- Report to HDC on the effectiveness of the changes made since the man’s care, and on any further improvements made.

Editors notes

The full report of this case can be viewed on HDC’s website - see HDC's ' Latest Decisions'.

Names have been removed from the report to protect privacy of the individuals involved in this case.

The Commissioner will usually name providers and public hospitals found in breach of the Code unless it would not be in the public interest or would unfairly compromise the privacy interests of an individual provider or a consumer. More information for the media, including HDC’s naming policy and why we don't comment on complaints, can be found on our website here.

HDC promotes and protects the rights of people using health and disability services as set out in the Code of Health and Disability Services Consumers' Rights (the Code).

In 2021/22 HDC made 402 recommendations for quality improvement and providers complied with 98% of those recommendations.

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