The director of Bainlea House, which traded as Bainswood on Victoria, told NZME he greatly appreciated the professional work that staff put into managing what was a challenging scenario and it was unfortunate the company had not achieved the right standard.
An investigation was started on August 1, 2022 and police were contacted about a week later.
They interviewed the woman but concluded that there was no clear disclosure of sexual offending and the police file was closed.
The Health & Disability Commissioner (HDC) has now found that Bainlea House breached a section of the health consumers’ code through not providing services to the woman with reasonable care and skill.
The findings of Deputy Health and Disability Commissioner, Carolyn Cooper, were guided by advice from an in-house registered nurse who identified a number of deviations from the accepted standard of care.
Deputy commissioner Carolyn Cooper found that the facility’s abuse and neglect policy was inadequate to guide staff actions when encountering potential or alleged sexual abuse.
Nor did staff escalate their concerns in line with the seriousness of the concerns, as required by the organisation’s policy.
Her findings were guided by advice from an in-house registered nurse who identified a number of deviations from the accepted standard of care, including photos taken by staff of the woman’s vaginal area, management of her pressure injury, weight loss and dietary needs.
The woman needed hospital-level care because of partial paralysis and difficulty swallowing because of an earlier stroke.
She needed full assistance with mobility by using a wheelchair and needed help to eat and drink.
She had difficulty expressing herself, which required staff to understand the sounds and gestures she made when communicating.
Her short-term memory was intact with no evidence of confusion in time or place, Cooper said.
A nurse recorded in clinical progress notes in July 2022 a conversation with the woman’s welfare guardian in which she raised concerns about the frequent and long outings of the woman and the man known to her.
There were also concerns about the condition in which she returned, with some evidence of her incontinence wrap having been tampered with.
The lengthy outings were also exacerbating the woman’s pressure injuries.
On July 24, 2022 it was noted that on the last round of the day, the caregivers found that the woman’s wrap was ripped on the right side and her genital area appeared red and swollen.
The caregivers contacted a senior staff member and together they proceeded to take photographs after asking the woman for consent.
They stated she gave this by moving her head and saying “Yes”.
Bainlea House acknowledged that some errors were made concerning the management of the woman’s incontinence wrap, including the taking of photographs and sending these to a daughter who was not the welfare guardian.
However, it did not agree that this amounted to a significant deviation from the accepted standard of care, because consent was provided by the woman for photos to be taken.
The care facility also acknowledged that the woman was not asked by staff whether she had consented to sexual relations with the man known to her, but her “distressed behaviour” made them believe she did not consent.
It acknowledged the error and that it had been addressed via a “corrective action plan” developed after the incident.
Bainlea House told the HDC that additional education was provided for all staff in August 2022 and repeated throughout 2023 and 2024, and included training in sexuality and intimacy, abuse and neglect, privacy, communication and critical thinking.
Cooper noted the in-house nurse’s comments on the corrective actions undertaken by Bainlea House were comprehensive and of good quality, with an emphasis on staff education.
“I acknowledge the changes made by Bainlea House and consider these to be appropriate in the circumstances.”
A recommendation was made that the care provider forward its apology to the woman’s family.
Renwick told NZME the company accepted the HDC findings and had apologised to the complainant.
“We’re confident we can learn and improve for the benefit of our residents and their families,” he said.
Tracy Neal is a Nelson-based Open Justice reporter at NZME. She was previously RNZ’s regional reporter in Nelson-Marlborough and has covered general news, including court and local government for the Nelson Mail.