Oceania Care Company Limited's Elmwood Village. Photo: Supplied
A man whose mother needed a leg amputation after staying at a rest home previously criticised by the Health and Disability Commissioner (HDC) says he was not told when she sustained serious injuries.
Oceania Healthcare, which operates Elmwood Village in Manurewa, Auckland, said it had strengthened operations following complaints to the HDC, and was committed to improving.
Oceania apologised last month following an HDC report about a bedbound woman who needed a skin graft because her bed was left too close to a heater with no guard, in 2022.
The 85-year-old woman described smelling burning flesh after her bed was pushed up against a heater, giving her second-degree burns.
The HDC report identified two breaches in relation to the incident.
Following RNZ's reporting, Andrew Ashe came forward with his late mother's experiences at the Manurewa rest home in 2023 and said he had filed his own separate HDC complaint.
Ashe said two serious incidents involving his mother were not immediately reported to him. In one, she fractured her femur and had to have her right leg removed.
His mother, Sheryl West, had been diagnosed with dementia, had chemotherapy for breast cancer and likely also had osteoporosis, he said. Her condition meant she could not walk or talk.
She had been a resident at Elmwood for about two years before she was moved to another rest home according to the family.
Ashe said his mother suffered two accidents while in Elmwood's care.
The first was a fall in the bathroom and the second probably occurred while she was being transferred into a wheelchair. Neither were immediately communicated to him, he said.
He said he did not know of the injuries until he was helping his mother change.
"All the way through pubic area, all of that was just purple and black from bruising. So I took photos straight away, like, what the actual [is] going on here? It was the top of the femur that was discovered to be fractured."
It likely happened while his mother was being transferred from bed to a wheelchair in a sling hoist, with her leg knocking into the wheelchair as staff lowered her.
Another possibility was that pressure was put on her leg by the sling being positioned incorrectly, he said.
West eventually had to have her leg amputated, he said.
"It's not going to bring mum back by all means, but I just want people to be able to trust that the system really can look after their loved ones as well," he said.
"Sure, she had dementia, and we'd found that she had a lump in her breast and stuff... the golden rule was, let's just keep her comfortable and give her what she needs."
Ashe said he understood that accidents happened, but he was disappointed he had to learn about the injury himself.
"I had to go back and tell them, and then they're like, 'Oh yeah, well, sorry, this happened, I didn't appreciate that.' They were the ones who admitted, 'Oh, we should have told you earlier,'" he said.
He subsequently removed his mother from the rest home. West died later in 2023, aged 72.
Commissioner: No breach found, but shortcomings identified
An HDC spokesperson said Ashe's complaint was thoroughly assessed but did not meet the threshold for formal investigation, and there was no breach of the code of patient rights.
"However, HDC was critical of several aspects of care and made recommendations to ensure appropriate remedial actions were taken to reduce the likelihood of similar situations occurring in the future and quality of care improves," the spokesperson said.
Ashe said he wanted assurances this would not happen to other families who placed their trust in Elmwood Village to look after loved ones.
"Elmwood need to put their hand up and say, 'Yeah, we stuffed up and we admit it.' And I want for future residents to be able to be in a place like that and know that we can trust them and know that they're going to be looked after."
The HDC said it would follow up.
Oceania Healthcare's response
RNZ put questions to Oceania Healthcare, which Elmwood Village comes under, after hearing Ashe's story.
Shirley Ross, director of clinical and dare services, said Oceania appreciated it had been a difficult and distressing time for Ashe and his family, and it took their concerns seriously.
The investigation into West's care did not identify systemic issues, but it had made significant changes since May 2023, she said, such as new leadership and strengthened clinical governance and escalation processes.
"This includes enhanced staff training, revised incident management, and independent audits. Elmwood recently achieved a full four-year certification with no corrective actions, demonstrating our commitment to continuous improvement and high-quality care."
Elmwood Village had been transparent with the HDC investigation and provided all the relevant documentation.
She noted that the HDC investigation included independent clinical advice from an experienced aged care nurse, and Oceania was not found to have breached the code.
Elmwood followed the HDC's recommendations to undertake further staff training on reporting, incident management, and communication with families about care plans, she said.
"We acknowledge that there were occasions when our communication with Mr Ashe about his mother's care did not meet the communication standards we set at Oceania."
"We met with Mr Ashe at the time and sincerely apologised for the distress this caused."
Ashe said he felt there should be some form of financial compensation, but he was not fixated on a large sum. Ashe said he was open, for example, to Oceania Healthcare refunding him for the time his mother spent at Elmwood Village.
"It's not about money for me, but moving forward, I think there should be something restorative. Just something symbolic to say, "Look, yeah, we did get it wrong…' Whatever that figure may be, I'm not going to sit here and say, 'I demand this amount.'"
Asked whether they were open to finding a resolution with Ashe that could involve financial compensation, Oceania said it was committed to listening to his concerns but any discussions would be private and confidential.
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