A young woman with a complex medical history ended up in hospital critical care with a severe kidney and lung infection after a residential care facility failed to closely monitor her deteriorating health.

The woman, whose medical history included a transplanted kidney and an allergy to the antibiotic Augmentin, didn’t receive the appropriate care from NZCommunity Living Limited facility when she became ill, the Health and Disability Commissioner [HDC] has found.

Aged in her 30s, the woman - whose identity is not listed - began living at the facility in September 2018.

Her parents had provided detailed information about the woman’s special needs and the support she required, including the close monitoring of any illness, particularly any that could result in her becoming dehydrated due to her increased risk of complications.

However between September 6 and 9, 2019, the woman had diarrhoea and felt unwell, and staff took her to see a GP on September 10.

The doctor advised them to bring her back to the medical centre if her symptoms worsened, if her condition did not improve over the next 48 hours, or if she showed further signs of illness, lethargy, or reduced fluid intake.

During telephone calls on the morning of September 13 her mother noticed she was coughing frequently and sounded breathless.

When her mother called the facility about 5.30pm to ask if her daughter could see the doctor again, she was told it was too late and a home visit was too expensive.

Her mother later picked up her daughter and took her to the emergency department, where she was admitted to the Critical Care Unit with a severe kidney and lung infection.

She spent two weeks in the unit and a further two weeks recovering in a hospital ward, the decision stated.

After their daughter’s admission to hospital her parents complained to the HDC they had lost confidence in NZCommunity Living’s ability to care for their daughter and she did not return to the facility following her discharge.

Deputy Commissioner Rose Wall found the facility breached the Code of Health and Disability Service Consumers’ Rights by failing to deliver services of an appropriate standard, provided with reasonable care and skill, in the decision released today.

Wall was critical of NZCommunity Living’s management of the woman’s condition after there was a clear deterioration in her health.

“There was a lack of monitoring and documentation of her food and fluid intake, and no short-term care plan was developed in response to a temporary change in health and support needs,” Wall said.

“In addition, her personal plan specifically noted that she was to be taken to hospital if she experienced both diarrhoea and vomiting, but this was not followed.”

NZCommunity Living told HDC it was first noticed the woman had vomited on September 10, which resulted in her being taken to the doctor.

Her health appeared to be improving until the afternoon of September 12, when it was reported she had vomited again, the facility advised.

NZCommunity Living discovered after the resident’s visit to the GP, a short-term support plan had not been created by the health advisor or the service delivery manager as per its policy.

The facility’s error in administering Augmentin to the woman for a urinary tract infection about two weeks before she became unwell, and the delay in recognising her reaction to the medication, were also criticised by Wall.

NZCommunity Living unreservedly apologised for giving the woman six doses of the drug and acknowledged medication management was an area for improvement.

“Our investigation found the doctor prescribed Augmentin despite it being listed as an allergy in [Ms A’s] medical centre notes,” it advised the HDC.

NZCommunity Living Ltd told the HDC it now used “the allergy stickers” on people’s medication files, and it was in the process of implementing the medication management system MediMap.

While Wall raised concerns about the lack of staff training and induction on relevant policies, care and risk management, she considered the omissions did not amount to a breach of the Code.

She recommended NZCommunity Living provide a formal written apology to the woman’s family for the breach of the Code and consider ways to use the report’s findings as a basis for staff training at its facilities.

Recommendations of refresher education for staff on short-term care plans, the management of a deteriorating condition, providing a progress report and key learnings following the use of “sticker alerts” on personal files, and on the implementation of MediMap were also made.