HDC Finds Man With Disabilities Failed By Support Services After Being Assaulted By Flatmate

Monday, 17 February 2025, 9:48 pm
Article: RNZ

The Health and Disability Commissioner has found a man with disabilities and high needs was failed by two support services - after he was assaulted by a flatmate and left injured after a physical assessment.

The man's mother, who is his welfare guardian, made two complaints to the HDC; one about the assessment made by a disability service in 2019 that left the man unable to use his arm, and another about an assault in 2021 by another resident at the IDEA Services home where he lived.

The man has cerebral palsy and a significant intellectual disability, uses a wheelchair and requires 24/7 support for his daily living needs.

In a report released on Monday, deputy Health and Disability Commissioner Rose Wall found IDEA Services, a fully owned subsidiary of IHC New Zealand, had breached the Code of Health and Disability Services Consumers' Rights by failing to provide the man with the appropriate standard of care as it failed to provide a safe living environment.

It said the other service provider, which it did not name, did not have sufficient information about the man's condition and should not have applied any physical force to his spine, without medical clearance.

Injury after disability service assessment

In 2019, the man had a physical assessment to assess his range of mobility. His mother agreed to the assessment on the condition she was present, but arrived to find it was already underway.

She said during it, the assessor bent the man over in his wheelchair with "tremendous force" before he indicated he had enough.

Shortly after, his mother noticed he was unable to use his right arm to hold onto a bar inside the car as he usually would.

A physiotherapist two days later suggested he may have a tear in his shoulder and a GP later assessed it as a sprain or muscle injury that would recover on its own.

An x-ray found nothing of concern and as a result, ACC declined cover.

The mother said the injury had changed her son's life dramatically, he was no longer able use his right arm and could not feed himself, use his electric chair properly, or lift himself for others to manage his toiletry needs.

An MRI scan 18 months later was reviewed by a doctor who said the man had a very tight spinal in several places that needed surgery to decompress.

He noted the changes in the man's spine were longstanding, but proposed the manipulation of his neck and spine by the disability service was the action that had caused the man to lose the function of his right arm, which he considered should be covered by ACC.

The commissioner found that the assessor had limited information about the man's condition before he undertook the assessment, that he should have discussed the man's history, abilities, and condition with his mother beforehand and that the assessment should not have involved

applying any force to the man's spine without having first had a medical clearance to do so.

Assault at IDEA Services residential home

IDEA Services began supporting the man in 2006 with respite care and then in 2008 with disability residential support.

In 2018, he was living with several others, including a flatmate who had moved into the house after a serious incident at another IDEA Services residence involving a staff member.

There were several incidents between the man and that flatmate, who has an intellectual disability, autism spectrum disorder and ongoing behaviour challenges.

On several occasions between 2018 and 2020, the flatmate was found to have entered the man's room and played with the electric bed controls and his wheelchair controls and in one case, had been found sitting on top of the man in his wheelchair. His mother, as his welfare guardian, had not been told of these incidents.

As a result, a privacy lock and door alarm were fitted in the man's room and his support plan said the alarm was to be used at all times when he was in his room by himself, with staff to check on him when it was activated.

In 2021, the flatmate was referred to another service for behavioural support. The service manager for the house said the other residents feared him and staff were worried about him doing something that could hurt the other residents.

He was known to slam his own bedroom door repeatedly for up to an hour, move furniture aggressively, throw things aimlessly and upend furniture in common areas.

A support protocol and several strategies were put in place to manage the flatmate's behaviour, that included removing staff and other residents from the environment to reduce the stimulation and de-escalate the event quickly.

Later in a 2021, staff found the flatmate sitting on the man's chest while he was in bed and hitting his genitals with a closed fist. The flatmate was removed from the room and the man was crying, had laboured breathing, graze marks on his chest and the area was red.

Staff had moved the sensor for the door alarm off that morning when showering the man and had forgotten to turn it back around afterwards.

IDEA Services told the HDC that if the door alarm had been operating as expected, staff would have been alerted when the flatmate entered the man's bedroom, and the incident could have been prevented.

It's policies state that family or an advocate) must be informed of serious incidents and that police must be notified if any type of abuse has occurred within a Regional Intellectual Disability Supported Accommodation Service.

The commissioner found there were deficiencies in the care provided to the man by IDEA Services' staff, systemic issues for which the service provider was responsible.

"A combination of inadequate care planning in relation to risk management, placement with a resident who exhibited inappropriate behaviour that escalated to violence, and poor management of incident reporting, placed Mr A in a position of vulnerability, and the care provided to him fell short of the accepted standard."

Wall said the provision of appropriate support services in the community could be a challenge for disabled people and their whānau.

People in residential supported living homes sometimes had limited choice in where and with whom they lived and the daily activities they undertook.

She said where there were limited options, the onus was on the provider to put procedures and safeguards in place to keep all residents safe.

"This report highlights the difficulties experienced by disabled people when they are living in a home with people with whom they are not compatible."

Recommendations

The commissioner recommended both IDEA Services and the other disability support service provide written apologies to the man and his family for the breaches detailed in the report.

It also recommended that IDEA Services; commission an independent review of its processes to identify risks arising from incidents, conduct an audit, over a three-month period, of compliance with incident reporting procedures and report back to the HDC on the development of a compatibility tool for flatmates.

It recommend the other disability support service develop a policy requiring its assessors to have reviewed medical assessments of clients before undertaking any physical manipulations and arrange for its staff to complete further training.

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