How one man ended up dead only a month after being admitted to a hostel

After five years of his family lobbying for an investigation, not a single person has been held accountable.




There is very little transparency in healthcare.  

Underneath the hyperbole of how 'we all respect our elderly citizens', secretive bureaucrats are withholding vital information about serious errors occuring in a small number of badly run nursing homes.  

Meanwhile, lazy politicians allow a culture of over servicing and expensive hospital centric health systems to bleed the health budget dry.

The result? There is no money for hiring and retaining good staff, bad staff slip through the cracks, and the most vulnerable members of society suffer the consequences.


A true story

An 70-year-old man we will call 'Carl' was was recovering from a slow healing leg ulcer. Apart from having insulin-dependent diabetes, Carl was medically stable.

He was independent, lived alone and was able to look after himself. However, Carl was lonely. His wife had died and his children were busy with their own families.

Carl went into hospital for the debridement of a leg ulcer. A family meeting was held several days later. After a discussion with his family and a social worker, Carl agreed to move into a low-level nursing home.


"The last thing I want is to be a burden on my family".



The hostel looked glamorous. It had thick carpet, furnished rooms, pay TV and a large communal space.


One of the first things to happen when Carl was admitted to the home, was his normal prescription of long-acting insulin was changed to a different brand of short-acting insulin.

Carl's General Practitioner was not advised of this change. Neither was his family.

Carl's blood sugars were not done often, even though the new medication caused his blood sugars to swing high, then low.

When Carl’s daughter first came to see him, she was upset to hear that her father's medications had been changed without any one being notified.

She started complained to the nursing staff about her father’s care.


"This is not good enough! You can't just change an old man's insulin without telling his Doctor, or his family. No wonder his blood sugars are unstable."


A week later Carl’s daughter walked in when he nurse was changing his leg dressing. She was shocked to see how badly her father’s wound had deteriorated.

The leg wound had been healing well when he came out of hospital. Now it was infected and deteriorating badly. Carl’s daughter was extremely upset.

She announced that she would be taking her father into the hospital emergency department the next day for a medical review.


“You could be in a lot of trouble” she told the nurse. “I’m going to write a formal complaint about this”.


Carl had become confused that evening and was put to bed early. Night staff checked his blood sugar when they came on shift at 9.30 pm and found that it was low. Carl was complaining of feeling sweaty and pulling off his pajamas.

Nursing staff also discovered that Carl had lost control of his bladder. They changed his night clothes and sheets. Then the nursing home Doctor was rung.

Over the phone the Doctor told the nurse to give Carl a sandwich to eat and some juice to drink. When the nurse was free, she took a sandwich down to Carl’s room.

By now Carl was asleep. The nurse told a care attendant to make sure Carl got the sandwich when he woke up.


Staff from the nursing home rang Carl's daughter overnight. They advised her that Carl had been 'unwell'. “What’s wrong” Carl's daughter asked, in a state of shock. “I was there only yesterday. What have you done?"


Early in the morning the nurse rechecked Carl’s blood sugar and found it was 1.5 mmol. Despite the fact that Carl had an oral sugar paste called glycogen on his drug chart for emergencies this treatment was not given to him.

It was written in the nursing home protocols that an ambulance was be be called if a resident’s blood sugar was below 2 mmol. However the nurse did not do this. Instead she rang the Doctor for the second time.

The doctor suggested giving Carl some jelly beans. The doctor did not call back to check on Carl’s progress.

The night nurses went in to give Carl a handful of jelly beans. By this time Carl was quiet again. The nurses woke him up and gave him a few.

After nursing handover at 7am the night nurse went home. The morning staff went to check the patients.

They found Carl dead.

It was six hours after the Doctor had been rung. Carls' blood sugar had not been checked for four hours.



Carl’s sister fought the aged care bureaucracy to make the nursing home accountable for her father's death. However the bureaucracy kept delaying, putting her off, saying it was the responsibility of another Department.

Nursing staff moved on to other facilities.

Carl's daughter heard from another relative that other residents had died in similar circumstances, but no one would give her more information.




When she finally got hold of her father’s medical notes under a Freedom of Information order, Carl's daughter noticed that a nurse had written in the notes that she had given a different insulin, to the one written up on the the drug chart.

Her father's blood sugars had been done very irregularly ever since he arrived in the home.

The nursing home refused to accept that they even had a problem with their management of her father's diabetes.




Carl’s daughter then took her complaint to every State and Federal Department connected to Aged Care.

She hired a lawyer.

She wrote to Members of Parliament and the media.

Everybody gave her sympathy. But nobody wanted to make the nursing staff, the Doctor and the nursing home responsible.

At the end of 5 years, all she had was a box full of letters and emails going back and forth, and thousands of dollars worth of legal bills.




Wikihospitals 2014

References

A spate of insulin murders, reports of abuse… How could this happen in our nursing homes? - Paywall, the Australian May 13th - 14th 2017 Trent Dalton.

Nursing home employee accused of killing patients sent texts predicting deaths, court hears - ABC August 2016 Karl Hoerr.

Ballina nursing home deaths: Police allege nurse gave deadly insulin shot to patients - ABC 8th July 2014.