‘I failed her, they failed me’: Qld nursing home tragedy
EDITH White suffered severe bruising and injury from nine falls over the final two weeks of her life.
The aged care home where she was staying called an ambulance only once, allegedly failed to hand over information to paramedics, provided inadequate pain management and did not get her prescribed medication because of a public holiday.
The 84-year-old dementia patient died a week after her last fall, from a heart attack less than three months after entering Ozcare Parkwood Gardens at Labrador.
Yesterday her grieving daughter told the Bulletin: "I trusted Ozcare, I gave them an otherwise healthy mother with dementia. In less than three months she was dead.
"I failed her, they failed me."
Ozcare said it is prevented from commenting on individual cases.
An Aged Care Quality Safety Commission (ACQS) report found the facility had no documented evidence that strategies were put in place to prevent Ms White's falls, despite her repeated falls between March 30 and April 11.
The only care plan provided by Ozcare was made just days before Ms White died on April 27, almost a month after she first began collapsing.
Following her most severe fall on March 30, Ms White was found on her bathroom floor, her face bruised where she sustained a head injury.
Despite the severity of the collapse, an ambulance was not called. Instead the dementia patient had "verbally denied she had pain".
She was not seen by a doctor until that evening, when it was noted there was no fracture and
it was recommended she be sent to hospital if staff were concerned.
The commission found Ms White's Alzheimers diagnosis and limited cognitive ability were not considered when care staff asked her about the severity of her pain following the falls.
The commission also found no evidence that Ms White was prescribed pain medication in the days following the fall on March 30, despite being observed to be in "moderate pain'' by staff.
Ms White's doctor was only notified of two of the nine falls that occurred over the two-week period.
ACQS found that over the same period, care staff had not documented evidence of how they treated swelling in Ms White's legs, which was first noted in March, despite care instructions from her doctor.
By April 10 "deep cracks'' had appeared in Ms White's skin.
Following her two final falls on April 10 and April 11, an ambulance was called on April 11.
In a report from the Queensland Ambulance Service, it was noted that nursing staff were "resistant to QAS presence'' and did not provide "clinical handover'' - a claim denied by Ozcare.
Ms White returned from hospital on April 18 to the aged care home, where her health deteriorated further.
The ACQS report also detailed concerns that medication had been prescribed but not given to Ms White on the evening of April 24, because of a public holiday the next day.
To reduce the elderly woman's distress, both an antihistamine and an antipsychotic had been prescribed on the afternoon of April 24.
But Ms White's daughter, Sally Lowndes, says she had to go and buy the medication herself because the home was out of stock.
"It was Anzac Day the next day. They left the script on the side bench and went," she said.
"They witnessed my mum screaming in pain, crying for her mum to help her.
"I went down and said what are we doing, they said we can't get to a pharmacy so I went.
"It was 24 hours until she got her medication."
Ms White died on April 27 after suffering a heart attack.
Ms Lowndes who visiter her mother daily said she felt she let her down.
She said her mother had worked hard to raise her alone in the forced adoption era of the 1960s.
"I grew up in Birmingham. Mum was alone and unmarried and fought so hard for me, to keep me and protect me,'' she said.
"When I flew her out here in September last year I thought I was returning her love.
"But I feel like I have failed her."
On November 21 the ACQS commission wrote to Ms Lowndes to say a number of resolutions had been made for the home. These included further staff education, email reminders and a new reference booklet.
But Ms Lowndes said these steps were not nearly enough to prevent another family going through the same trauma.
Instead, she said the "box ticking'' would only add to the stress on overworked staff.
"The deterioration that happened in that time was alarming, even to others who knew her," Ms Lowndes said.
"The staff were beautiful, they were asking me to help but they were limited in what they could do.
"The report has come through all well and good but how many extra medical staff have they put on? All they have done is added a tick and flick.
"These really are forgotten people."
Ms Lowndes said she wanted accreditation to mean accreditation.
"This is an emergency, it might not just be your mother or your father, it could be you."
A spokesperson for Ozcare said the company "worked with the Aged Care Quality and Safety Commission to ensure that we have the best possible standards and we continually monitor our levels of care."
The Aged Care Quality Safety Commission could not make information on special cases public and could not confirm if a spot audit has occured since the complaint.