Nurse Maude Breaches Standard Of Care Stopping Insulin Checks And Catheter Care 20HDC00940

A man's rights under the Code of Health and Disability Services Consumers’ Rights were breached by Nurse Maude while he was receiving its in-home care services, the Deputy Health and Disability Commissioner has found.

In a decision released today, Dr Vanessa Caldwell said Nurse Maude had not provided services to the man with reasonable care and skill. The man had been residing in an independent living unit until he was admitted to hospital. He needed rest home level care from the time he was discharged until he passed away.

"Mr A's family believes that failures by Nurse Maude caused, or contributed to, the decline of his health to the extent that he could no longer live independently. I offer my condolences to his family for their loss," she said.

The findings relate to the management of the man's insulin injections and catheter. The man had been administering his own insulin but started to struggle with this, so a registered nurse organised daily checks. When he appeared to be back on track with his self-management, this was reduced from daily checks to checks occurring during his scheduled catheter care visits.

However, as a result of human error, he did not have any further catheter care visits scheduled. The man called Nurse Maude requesting a new catheter bag a month, but that call was never actioned.

After not receiving catheter care for four months, the man was taken to a hospital emergency department. He was found to be suffering from an urinary tract infection, and he had life-threatening complications from an extended period of high blood sugar due to missed insulin injections. Some cognitive decline was also noted.

Dr Caldwell agreed with expert advice that there had been a serious departure from accepted practice when Nurse Maude did not notify the man's GP when his insulin management was reduced, particularly given his earlier experiences.

She was also critical of its discharge management at the time. "The erroneous discharge, caused by an inadequate process at Nurse Maude, created the situation where Mr A was not receiving any district nursing care for months, while his family and GP were unaware the visits had stopped. With no clinical intervention, Mr A's deterioration and hospital admission was not unexpected," she said.

Dr Caldwell commented that the care home company's clinical documentation of its review of the events was inadequate.

Dr Caldwell recommended Nurse Maude formally apologise to the man's family, develop a system to manage the central coordination of clients needing catheter care, and provide HDC with the results of a three-monthly audit of its adherence to a district nursing discharge procedure from 2022 to the present.

She recommended the care home company provide education and staff training on clinical documentation, and audit adherence to its policy on responses to call bells and emergency procedures. All recommendations are to be reported back to HDC.

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