{"id":614212,"date":"2026-09-28T10:32:10","date_gmt":"2026-09-28T10:32:10","guid":{"rendered":"https:\/\/www.newsbeep.com\/nz\/614212\/"},"modified":"2026-09-28T10:32:10","modified_gmt":"2026-09-28T10:32:10","slug":"hdc-finds-rawene-hospital-breached-patients-rights-after-falls-and-death","status":"publish","type":"post","link":"https:\/\/www.newsbeep.com\/nz\/614212\/","title":{"rendered":"HDC finds Rawene Hospital breached patient\u2019s rights after falls and death"},"content":{"rendered":"

Now, the Health and Disability Commissioner (HDC) has found Rawene Hospital breached the man\u2019s rights to care, particularly in falls risk assessments.<\/p>\n

In a finding released today, the commissioner said the man\u2019s GP reviewed him after a two-to-three-week decline that resulted in increased confusion, reduced interaction with his family, worsening mobility, pain without a clear cause and worsening incontinence.<\/p>\n

The man was admitted to Rawene Hospital<\/a> on October 27, 2021, for inpatient assessment and respite care, including a review of his support needs.<\/p>\n

His wife told staff he was susceptible to falls and requested a side rail be placed on his bed, but that did not occur.<\/p>\n

Documents provided to the HDC showed no falls risk assessment or consent form for the bed rail was completed by the hospital until several days after his admission.<\/p>\n

On November 1, staff documented the man was unable to walk and about 3am the next day he was found in a frozen position near a roommate\u2019s bed.<\/p>\n

The notes did not make clear whether he was standing or sitting and the incident was not noted as a fall.<\/p>\n

At 6.45am, the man was found on the floor after an unwitnessed fall and two hours later he had another unwitnessed fall, this time causing a laceration on his head.<\/p>\n

Throughout the night, the man had been unable to pass urine and there was no documentation to show whether this was further assessed.<\/p>\n

Neurological assessments were not carried out until some time after his last fall.<\/p>\n

He was transferred to Whang\u0101rei Hospital<\/a>, where a large intracranial haemorrhage was confirmed to be inoperable and he was sent back to Rawene for palliative care.<\/p>\n

On November 5, he had another fall as his condition deteriorated and he died.<\/p>\n

The family sent a formal complaint to the hospital but, unhappy with its internal investigation and response, complained to the HDC.<\/p>\n

Health and Disability Commissioner Vanessa Caldwell found Rawene Hospital<\/a> breached the Code of Health and Disability Services Consumers\u2019 Rights and made several notes and recommendations.<\/p>\n

Caldwell found multiple missed opportunities to identify the man\u2019s falls risk and care planning was not completed in a timely manner.<\/p>\n

\u201cClinical documentation regarding Mr B\u2019s mobility status was inconsistent, which reduced clarity for staff and affected their ability to provide appropriate supervision and assistance,\u201d she said.<\/p>\n

\u201cIn addition, there was a failure to recognise and respond to changes in Mr B\u2019s condition, including confusion, altered behaviour, and unsafe attempts to mobilise. These changes were not adequately assessed or escalated.\u201d<\/p>\n

\"HealthHealth and Disability Commissioner Dr Vanessa Caldwell made a number of recommendations. Photo \/ James Gilberd Photography<\/p>\n

Caldwell also found his urinary issues were not followed up and consent for a bed rail could have been obtained early in his admission.<\/p>\n

Rawene Hospital has since developed new restraint policies, education and training on falls risks, and redeveloped procedures relating to assessment and care planning.<\/p>\n

The commissioner also recommended a formal written apology and evidence of the policy changes and training, including urinary retention, be provided to the HDC within six months.<\/p>\n

A random audit of 15 patients over the past six months has also been requested to ensure records are clear and consistent.<\/p>\n

Rawene Hospital acknowledged the family\u2019s concerns and recognised \u201cthat this remains a deeply challenging and emotional process, and we extend our sincere aroha and respect to the wh\u0101nau for their patience and engagement throughout this investigation\u201d.<\/p>\n

Shannon Pitman is a Whang\u0101rei-based reporter for Open Justice covering courts in the Te Tai Tokerau region. She is of Ng\u0101puhi\/Ng\u0101ti P\u016bkenga descent and has worked in digital media for the past five years. She joined NZME in 2023.<\/p>\n

Join the NZ Herald\u2019s Open Justice team for Case by Case<\/a>, a video and podcast series examining the disputes and decisions making headlines across New Zealand. <\/p>\n","protected":false},"excerpt":{"rendered":"Now, the Health and Disability Commissioner (HDC) has found Rawene Hospital breached the man\u2019s rights to care, particularly…\n","protected":false},"author":2,"featured_media":614213,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[5],"tags":[45782,5811,74,95,13916,11421,138,536,634,38403,15248,11424,11423,1861,2241,111,139,69,6293,21940,207,46859,143627,12718,6102,1316,1842],"class_list":["post-614212","post","type-post","status-publish","format-standard","has-post-thumbnail","category-business","tag-84yearold","tag-admitted","tag-after","tag-and","tag-asked","tag-breached","tag-business","tag-care","tag-death","tag-falling","tag-falls","tag-finds","tag-hdc","tag-history","tag-hospital","tag-new-zealand","tag-newzealand","tag-nz","tag-patients","tag-placed","tag-rail","tag-rawene","tag-respite","tag-rights","tag-side","tag-when","tag-wife"],"_links":{"self":[{"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/posts\/614212","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=614212"}],"version-history":[{"count":0,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/posts\/614212\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/media\/614213"}],"wp:attachment":[{"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/media?parent=614212"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/categories?post=614212"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/tags?post=614212"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}