A woman who was in hospital after recently having her leg amputated found herself being watched as she got changed, touched while she slept and had numerous sexual comments made to her by another patient, a male.

The incidents, of which there were at least eight, became so disruptive to the woman’s recovery that her family opted to check her out of hospital early and manage her care at home.

Now, Hutt Hospital has been asked by the Health and Disability Commissioner to apologise to the woman for failing to provide a safe environment for her to recover in.

According to a ruling released today, the woman was an inpatient at the hospital in 2022 for post-operative care for an amputated leg. She was in a female-only room with other patients, but the wider ward was mixed gender.

During her admission, a “confused” male patient began showing her unwanted attention. The hospital looked at his medication and gave him additional nursing time, redirecting him away from the woman. Staff also checked on him more regularly and gave him an alarm bracelet.

However, his behaviour towards the woman continued to escalate and after the sixth day a one-on-one healthcare assistant was assigned to him on a 24/7 basis.

A day later, he made his way into the woman’s room, prompting the hospital to offer her a private room which she declined. A security guard was then posted outside her door.

However, that guard wasn’t given specific instructions not to let the man in, and the man made it inside.

The woman’s family checked her out of the hospital 11 days after she was admitted and then made a complaint to the Health and Disability Commissioner (HDC) about her treatment.

In response to the HDC’s investigation, Health New Zealand said that a coordinated approach had been taken to prevent further incidents, but because of resourcing constraints, staff couldn’t move the man to another ward, and it could have added to his confusion.

Health NZ told the HDC it was a complex situation and said the male patient had high and complex health needs that required intensive management.

However, it acknowledged that despite the measures put in place, the incidents continued to occur and apologised for this and for the emotional distress it caused the woman.

It has since changed its policy for risk, particularly older patients who have challenging behaviours, including updating staff when they have a high needs patient and changing the ward layout to be less stimulating for confused patients. There are plans to install a security system at the front door of the ward.

The now former Deputy Health and Disability Commissioner, Carolyn Cooper, said that the woman should have been provided with a safe environment while she was a patient at Hutt Hospital.

Aged Care Commissioner Carolyn Cooper. Photo / supplied

Cooper said that the man’s behaviour escalated after having begun on the first day of the woman’s admission to the hospital.

“In addition, it appears that the instructions and information given to the healthcare assistant and security guard were unclear …” Cooper said.

“In my view, without the appropriate information, the utility of these measures was limited.”

Cooper acknowledged that the hospital did put measures in place to try to keep the woman safe, but ultimately, they were not effective, and the incidents continued to occur until she was discharged.

“… I have concerns that the male patient remained in the ward when it was clear that his behaviour was escalating and could not be managed adequately by the measures taken to minimise the risk of harm to [the woman],” Cooper found.

Cooper said the hospital breached the Code of Health and Disability Services Consumers’ Rights and recommended that it apologise to the woman, and prepare an anonymised case study based on the events to educate staff at the hospital.

Jeremy Wilkinson is an Open Justice reporter based in Manawatū, covering courts and justice issues with an interest in tribunals. He has been a journalist for nearly a decade and has worked for NZME since 2022.