justice system<\/a> in November 2022, when he was 19, \u201cseverely departed\u201d from accepted standards.<\/p>\n\u201c[Mr B] entered the justice system because of his own actions. He spent over four months being supported in that system with no apparent ill effects,\u201d Taylor said.<\/p>\n
\u201cWithin six months of support with [the provider] he was 20kg heavier, pre-diabetic and then passed away due to becoming ill, most likely from something he ate causing sepsis exacerbated by pre-diabetes,\u201d he said.<\/p>\n
\u201cHis symptoms weren\u2019t noticed until it was too late to save him.\u201d<\/p>\n
The man\u2019s death in hospital in May 2023 followed a multi-organ failure, with diabetic ketoacidosis triggered by an infection, which in turn appeared to have been caused by the man ingesting something which had perforated his gastrointestinal tract. <\/p>\n
His mother complained to the HDC that the provider and its staff did not monitor and care for her son adequately and did not manage his PWS.<\/p>\n
While the complaint was being investigated, the provider admitted that it had breached the part of the Code of Health and Disability Consumers\u2019 Rights which guarantees that people are treated in a way which minimises potential harm.<\/p>\n
\u201cThe peers I consulted unanimously agreed that the support severely departed from the accepted standard, and they were dismayed that these departures could happen to the extent that they did and with the outcome that occurred,\u201d Taylor said.<\/p>\n
Deputy Health and Disability Commissioner Rose Wall has now referred the man\u2019s death to the coroner, and the care home provider to Work Safe NZ, to determine if further action is called for.<\/p>\n
The man\u2019s identity and the name and location of the care home have been redacted from the public findings in the case. The man is referred to as Mr B.<\/p>\n
Wall accepted Taylor\u2019s advice that the severe departures from the accepted standard of care stemmed from the care home\u2019s poor systems, and inadequate staff oversight and support.<\/p>\n
However, she said no particular individual involved in the man\u2019s care should be blamed.<\/p>\n
![\"Deputy]()
Deputy Health & Disability Commissioner Rose Wall found the care home provider had breached the code of health consumers’ rights. Photo \/ HDC<\/p>\n
\u201cThe provider should have had robust policies and procedures in place and should have provided training, support and oversight to its staff members in order to provide a supportive and safe environment for Mr B,\u201d Wall said.<\/p>\n
\u201cI find that the provider did not provide services to Mr B in a manner that minimised harm to him or optimised his quality of life.\u201d<\/p>\n
She found that this breached the code of health consumers\u2019 rights.<\/p>\n
Wall told the care home to write an apology to Mr B\u2019s family, audit the care plans for all its residents, revise its procedures for inducting and training staff, develop guidelines on how to write records, and conduct a comprehensive review of daily notes and shift handovers for residents under specialist care.<\/p>\n
She recommended that the provider provide further training to its staff.<\/p>\n
Ric Stevens spent many years working for the former New Zealand Press Association news agency, including as a political reporter at Parliament, before holding senior positions at various daily newspapers. He joined NZME\u2019s Open Justice team in 2022 and is based in Hawke\u2019s Bay. <\/p>\n","protected":false},"excerpt":{"rendered":"His parents later found a receipt for an \u201cenormous\u201d Indian takeaway ordered about 10 days before he died.…\n","protected":false},"author":2,"featured_media":241805,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[3],"tags":[142127,28430,74,95,536,58631,6179,1054,90053,42,134,8788,1345,221,5158,3234,43,1560,4739,61,40,38,41,39,4741],"class_list":["post-241804","post","type-post","status-publish","format-standard","has-post-thumbnail","category-headlines","tag-20kg","tag-admission","tag-after","tag-and","tag-care","tag-commissioners","tag-died","tag-disability","tag-gained","tag-headlines","tag-health","tag-highlights","tag-home","tag-how","tag-man","tag-months","tag-news","tag-report","tag-six","tag-to","tag-top-news","tag-top-stories","tag-topnews","tag-topstories","tag-young"],"_links":{"self":[{"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/posts\/241804","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/comments?post=241804"}],"version-history":[{"count":0,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/posts\/241804\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/media\/241805"}],"wp:attachment":[{"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/media?parent=241804"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/categories?post=241804"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/tags?post=241804"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}