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Chris McKeen/Stuff
The care a man received at Edmonton Meadows Care Home has been referred to the health and disability commission.
The death of a retired military engineer has been referred to the health and disability commissioner after he was found lying on the pavement outside a rest home he lived in.
James More, 89, died on November 23, 2019, of a stroke which was complicated by blunt force injuries he received after falling on the pavement.
More, who spent 20 years as a flight engineer in the Royal New Zealand Air Force, was living at the dementia unit at Edmonton Meadows Care Home in Henderson prior to his fall.
In a recently released coroner’s report, Coroner Tania Tetitaha, noted More would go for walks in an outside area three or more times a day.
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Residents were able to open the doors to the outside area, until 6pm, when the doors were normally locked.
More was “susceptible” to falls, Coroner Tetitaha said, and his family were concerned about him going on unsupervised walks.
A registered nurse at Edmonton Meadows said More often wouldn’t listen to staff and would become agitated.
“When that happened we would let him do what he wanted, including going outside for a walk.”
Staff were meant to check on More every 15 minutes during these outdoor walks.
Coroner Tetitaha noted there was no record of these checks occurring. There was also no explanation of how More was able to leave unsupervised when the doors were meant to be locked.
At 6.30pm on November 16, 2019, More was found by caregivers and members of the public lying face down outside the rest home.
Coroner Tetitaha said the caregivers stated they checked on him five minutes earlier.
More was taken to Waitākere Hospital and eventually discharged to family for end of life care.
“It’s possible if there were no blunt force injuries from the fall he may not have died,” Coroner Tetitaha noted.
“His family are unhappy about the level of supervision he received while going outside for walks.”
More had previous falls at the rest home, with his medical notes showing he had a fall earlier that month that was unwitnessed.
His care plan noted his falls risk was “medium” and his mobility was “independent but needs supervision”.
It also noted a staff member should be “within arm’s length” of More when he was walking.
“Whether there was an adequate falls risk assessment requires further investigation,” Coroner Tetitaha said.
Chris McKeen/Stuff
The exterior of Edmonton Meadows Care Home in West Auckland’s Henderson.
“This would be best investigated by the health and disability commissioner. There’s public interest in ensuring there were no breaches in the care received.”
A family member of More’s said the treatment More received at the care home “could’ve been better” and the communication to the family had been poor.
A letter of care plan provided to Coroner Tetitaha from Edmonton Meadows suggested changes had been made to prevent similar incidents including alarms on exit doors and patients wearing helmets on walks, if this was agreed to by family.
Coroner Tetitaha referred the case to the health and disability commission.
The management team at Edmonton Meadows said they had no comments to make before the investigation was complete.
They would not say if they knew how More ended up outside when the doors were meant to be locked at 6pm.
The health and disability commission said it couldn’t talk about the complaint.
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