Woman lay dead more than two days in supported accommodation

RNZ News

23-06-2025

Photo:
123RF
A woman with an intellectual disability living in supported accommodation lay dead for more than two days before staff found her, an investigation by the Health and Disability Commission (HDC) has found.
In a just-released decision, Deputy Health and Disability Commissioner Rose Wall said Spectrum Care Limited breached the woman's rights by failing to ensure she was taking her anti-epilepsy medication or carry out adequate checks on her well-being.
A post-mortem examination found the woman in her 30s, who died in early 2021, had not been taking her medication as prescribed.
The report noted the woman (Ms A), who had suffered a traumatic brain injury as a toddler, was "determined to live independently" and often refused help.
"Ms A shared Spectrum support workers with the person living in the flat next to hers, and she was able to be supported 24/7. However, mostly the support she received was at her own request."
Unless she asked for help, she was usually checked once a day - "or not at all if staff did not want to anger/wake her".
She had a long history of threatening and physically aggressive behaviour towards staff and police, but over the years, Spectrum had given her support with "anger management" and trained caregivers in behaviour support strategies.
Wall said Spectrum "should be commended" for supporting Ms A to live independently, but it failed to adequately mitigate the risks.
She had her medication for epilepsy and diabetes in blister packs, at her request.
"Staff were supposed to remind her daily to take her medication, and if she was in a 'good mood' she would take them.
"In 2021 there are three recorded instances when A refused to take her medications. Spectrum noted that if A was angry, she would refuse and sometimes throw the medications over the fence or onto the roof, and sometimes she would hide the blister pack so that staff could not check it."
The caregiver who delivered her evening meal said she could still hear music playing from Ms A's apartment the next morning, "which made her think that A must be in a good mood, although she did not see A all day".
A second caregiver, who came on duty at 3pm, went to ask Ms A what she would like for dinner, but saw she was in bed with music playing. He assumed that was sleeping "and did not want to wake her as this could trigger aggressive behaviour".
He went to her flat again the next day at 11am and saw she was still lying in the same position.
He entered the flat, called her name, and shook her body but she could not be roused.
An independent investigation commissioned by Spectrum after her death found Ms A had been assessed as needing 24/7 support with day-to-day needs.
In practice, this occurred on a once-a-day basis only, unless Ms A requested additional support or not at all if staff did not want to wake/anger her.
Sean Stowers, Spectrum Care chief executive officer.
Photo:
RNZ / Cole Eastham-Farrelly
"It was established that A had not been seen face-to-face by staff for more than one day."
Ms A operated "in a high-trust system and he was known to occasionally break that trust".
"This inevitably put her at risk, and there were insufficient checks and balances in the system to mitigate those risks. [Ms A's] policy of only allowing staff into her space when it suited her was also a risk. While it honoured her independence, it also prevented staff from monitoring her welfare and compromised their duty of care.
"Staff trusted her to take her medicine, but there was no way to check that she had taken it at the right time. When she died, which was probably on the night of [Day1] or in the early morning of [Day 2], it became clear that she had not taken any of her prescribed medication [for the last few days]. This put her at risk and staff had no way of knowing she was at risk."
Spectrum has since introduced a 'Self-Administration of Medicine Agreement' outlining the conditions for clients who control their own medication.
Rose Wall.
Photo:
Supplied / HDC
An expert adviser to the HDC, John Taylor, said a once-a-day check-in for someone with "very high support" needs was a severe departure from both the expected standard of care and the contract.
"It is concerning that it took such a tragic event for Spectrum to develop and implement a new SOP [standard operating procedure] outlining that wellbeing checks of residential consumers should occur at least thrice daily."
Regarding the lax oversight of Ms A's medication, Taylor said this was "a severe departure from the expected standard of care".
Allowing people the "dignity of risk" meant respecting a person's autonomy and self-determination to make his or her own choices, but also providing appropriate safeguards, information and strategies to "minimise the risk of harm", he said.
"To be clear, there is no 'dignity' for a person if they are left to face the consequences of risks they could not foresee, manage or understand."
Wall said Spectrum had accepted the finding of "an organisational breach", and had itself identified "service-level failings".
She directed the provider to apologise to Ms A's mother and family for the issues identified in the report, and revise its operating procedures to include alternative ways of doing wellbeing checks and medication reminders.
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