GPS data helped a community health service to untangle an employee's web of lies that covered up her failure to check on an elderly client just days before he died.

The support worker lied about attending her scheduled Saturday 90-minute session with the elderly man at his home in 2018, a Health and Disability Commissioner report has found.

The woman was in fact at her own home - around 11km away - at the time of the session, according to GPS data abstracted from an app used by support workers to log their visits with clients.

Names of the worker and the community health service are suppressed in the report to protect privacy.

Another support worker attended the man's house the following day but he didn't answer the door. The support worker was told she could leave by a family member of the man because sometimes he liked to sleep in on Sundays.

But on Monday he again didn't answer the door when another worker arrived.

She gained entry to the house and found him unconscious on his bedroom floor in a distressed state.

She called an ambulance and he was taken to hospital but died shortly afterwards.

The man, in his eighties, lived alone. He had kidney disease and osteoarthritis among a range of illnesses. He had received in-home support services from the community health service since 2015.

Because it was unclear exactly when the man fell, Deputy Commissioner Rose Wall could not comment on whether a visit by the support worker on Saturday would have led to him being found "incapacitated" earlier, the report said.

But the community health service was condemned for an "inadequate, delayed and piecemeal" investigation into the incident.

Investigation

The man's family enquired about his care following his death, but it was not treated as a complaint and no investigation followed by the community health service.

It only investigated after a complaint was made to the Health and Disability Commissioner six months later.

The community health service then formally interviewed the woman who failed to attend the scheduled Saturday session, in February 2019.

She claimed she went to his home and recollected there was a "strong smell of urine" and it "smelt of cigarette smoke".

She lied in another interview a month later and in a written statement to the community health service.

In a further interview in October 2019, the support worker claimed she didn't have any concerns for the man's health during her visit, "directly contradicting" her earlier statement.

In a statement to the Health and Disability Commissioner, the woman said: ""[S]ince that day I deeply regret that [I did] not pick [up] any signs and if I had known I would have done my best to help."

At that time, the community health service told the Health and Disability Commissioner it was "not ideal" that she did not log in and out of the visit on the app in real time, but it did not consider this as misconduct or relevant to the man's subsequent death.

But later data taken from the app used by support workers showed she was not at the man's home but indeed at her own home between 10.41am and 1.33pm.

The woman claimed the app "does not show the correct location and there is always discrepancies" but the health service disagreed.

Recommendations

Deputy Commissioner Rose Wall said the woman's failure to attend her weekly session with the man is concerning given that vulnerable clients rely on their support workers to check they are safe and well "at the very least".

"This would have enabled correct escalation procedures to be followed, and safety-netting measures to be instigated," she said in the report.

She found the support worker breached the Code of Health and Disability Services Consumers' Rights.

The report recommended the community health service consider further training for the woman on the "importance of logging her attendance", and for it and the woman to formally apologise to the man's family.

It also recommended that the community health service consider whether staff attendance at clients' homes should be routinely monitored or randomly audited.