A Balclutha rest home has been told to apologise to the family of a 92-year-old woman who was hospitalised after being given the wrong dosages of fentanyl.

The Aged Care Commissioner’s decision was issued yesterday and said there was a “departure from the accepted standard of care” at Clutha Views rest home, where the woman resided.

The woman, who is only named as “Mrs B” in the report, had been experiencing long-standing chronic sciatic pain and was on regular pain relief.

The pain relief included fentanyl transdermal (skin) patches, along with as-needed OxyNorm capsules.

Her plan to manage her pain was paracetamol 1g three times a day, and fentanyl patches to be changed every 72 hours.

But the application of the patches was not synchronised, and the patches were changed on different days.

The woman was eventually transferred to hospital after she reported to rest-home staff that she was not feeling well and had a “burning sensation” over her body and had been unable to sleep for the last two nights.

According to Medsafe,4 fentanyl is a medicine used to “relieve chronic or long-lasting pain, which requires strong painkillers” and is an opioid.

The decision did not name anyone involved in the incident, including the 92-year-old woman, and did not provide dates when this incident occurred.

“I consider that Clutha Views failed to provide services to Mrs B with reasonable care and skill,” the decision says.

“While there is individual accountability for these omissions (discussed later in the report), in my view the continued repeated omissions of several staff responsible for the incorrect fentanyl administration and documentation from 20–30 Month1, YearA is to some extent a systemic and organisational issue, for which ultimately Clutha Views is responsible.”

Heritage Lifecare, which owns Clutha Views, said it accepted the Aged Care Commissioner’s findings and had no additional comments to make.

“In the provisional opinion, I recommended that Clutha Views Lifecare and Village provide a written apology to the woman’s family for the issues identified in the report. Clutha Views Lifecare and Village has provided this apology to the commissioner, and it will be forwarded to the family,” the findings say.