Community nursing organisation Nurse Maude stopped giving a man in his 70s insulin checks and catheter care for four months following a “human error” in its discharge process.
A Health and Disability Commissioner (HDC) report released today detailed the man’s care and found that Nurse Maude had not provided services to the man with reasonable care and skill.
The findings relate to managing the man’s insulin injections and catheter.
While residing at an independent living unit, the man, who was diabetic and fitted with an indwelling catheter, had been administering his own insulin but started to struggle, meaning a registered nurse needed to conduct daily checks.
When he appeared to be back on track with his self-management, the man’s insulin checks were reduced from daily to when he underwent his scheduled catheter care visits.
However, because of “human error in the discharge process” for his insulin management, the man had no other scheduled catheter care visits.
He called Nurse Maude requesting a new catheter bag, but this was “never actioned”.
The man didn’t receive catheter care for four months and needed hospital treatment.
It was found the man had suffered a urinary tract infection. He also suffered “life-threatening complications” due to his extended period of high blood sugar due to the missed insulin injections.
“Some cognitive decline was also noted,” the report says.
The man’s family said: “He doesn’t recall the four weeks he spent in hospital or recall how and why he was admitted into hospital. Memory loss is so severe that Dad doesn’t recall his independent apartment, where he lived for nearly a year.”
Following his discharge, the man needed rest home-level care until his death.
Deputy Health and Disability Commissioner Dr Vanessa Caldwell found Nurse Maud had breached the man’s rights by not providing services to the man with reasonable care and skill.
“[The man’s] family believes that failures by Nurse Maude caused, or contributed to, the decline of his health to the extent that he could no longer live independently. I offer my condolences to his family for their loss,” she said.
Caldwell was highly critical of the organisation’s failure to inform the man’s GP that his insulin management had been reduced. She called this a “serious departure from accepted practice”.
She was also critical of Nurse Maude’s discharge management at the time.
“The erroneous discharge, caused by an inadequate process at Nurse Maude, created the situation where [the man] was not receiving any district nursing care for months, while his family and GP were unaware the visits had stopped.
“With no clinical intervention, [the man’s] deterioration and hospital admission was not unexpected,” she said.
Caldwell also called the care home company’s clinical documentation of its review of the events “inadequate”.
She recommended Nurse Maude formally apologise to the man’s family, develop a system to manage the central coordination of clients needing catheter care and provide the HDC with the results of a three-monthly audit of its adherence to a district nursing discharge procedure from 2022 to the present.
In a statement to the HDC, Nurse Maude said: “This occurred as a result of human error and we apologise unreservedly for this. This has been a clear failure of our processes, and as a result of this incident, we have reviewed how we do things and made changes to scheduling practi[c]es.’
Caldwell also recommended that the care home the man was staying in educate and train staff on clinical documentation and audit adherence to its policy on responses to call bells and emergency procedures.
