The royal commission heard the tragic case study of an elderly Italian migrant on Wednesday, and the failings at the aged care facility where she lived that contributed to her death.

The woman was born in southern Italy, but came to Australia at the age of 23, where she married and worked as a seamstress. As she aged, she developed dementia, diabetes, arthritis and arrhythmia. She moved into a Melbourne aged care facility at the age of 93.

Case study revealed a multitude of failures

During her time at the facility, the woman lost 10 per cent of her body weight, and yet her weight was not properly monitored.

She also had a number of falls, with the most serious resulting in a broken hip for which she required an operation. Upon returning to the facility from hospital, a surgical staple holding the wound together was left in her skin for weeks longer than recommended.

As a result, the wound became infected and the woman had to return to hospital to have the staples removed.

After returning to the nursing home, the woman developed a pressure ulcer on her heel. The wound was neglected by staff until it became infected. The wound would have been excruciatingly painful, and yet the woman’s pain was not assessed.

The woman was heavily medicated with the sedating drug quetiapine, and the royal commission heard the dosage was increased tenfold during one month alone.

Staff reluctant to tell when maggots found in pressure wound

The royal commission heard that four months after the heel pressure sores was first identified, maggots were found by care workers in the wound.

The nurse manager at the finacility tried to dissuade the woman’s GP from informing the resident’s family about the discovery of the maggots, and downplayed the seriousness of the matter when the family were informed.

“She went on to say… that maggots are used in modern medicine. She has used them herself and was essentially trying to downplay the significance of the whole thing,” the woman’s daughter told the royal commission.

The nurse manager was also fearful of escalating the “bad news” about the maggots up the facility’s hierarchy.

New facility found for palliative care

Not long afterwards, the woman required palliative care and was given a special room for the purpose. However, with staff regularly using a basin in the room, the family considered the room to be unsuitable.

The family eventually moved the woman to a different palliative care unit. 

The woman’s daughter told the royal commission, “At this point my mother’s management had been so poor, her pain management and her care and I had just completely lost faith.

“I just wanted her out of there.

“I believe would still be alive today if her pain and care had been properly managed,” she said.

The woman died two days later, in part due to the infected pressure wound.

Quality Commission found “significant gaps” in care 

A damning response from Aged Care Quality andSafety Commission to a complaint by the woman’s family read:

“On examination of all the available information, we have found that there were significant gaps in the care provided for your mother’s pressure wound. Although the wound was present on her return from hospital, it was not managed effectively to promote healing. The pain associated with the wound was not assessed or managed effectively until later when it was acknowledged that the wound would not heal. Medical and specialist intervention was delayed until the stage of the wound was irreversible. Documentary assessment and monitoring was unsystematic, inaccurate and did not provide a clear picture of the care required or being given.”

Facility passed assessment despite serious concerns

Despite the serious findings by the Commission, no sanctions were imposed on the facility. 

The Commission closed the complaint on the understanding the facility had addressed its concerns. 

Four weeks after the woman’s death, the facility was assessed by the then former Aged Care Quality Agency as meeting the quality standards for clinical care and skin care. It passed all 44 quality standards.

An internal investigation of the woman’s care eventually led to the chief executive officer of the facility being terminated from her role. The CEOs’ name was not revealed at the royal commission as he is challenging some of the statements made in submissions that are about him.

Chairman, CEO admit to failures of care

Counsel assisting the commissioner, Peter Rozen, asked the chairman about the Commission’s damning findings. 

“It’s really hard to imagine a more serious finding being made about an organisation that exists solely to provide care for elderly people isn’t it?” he asked.

“Correct, it is,” the chairman replied.

The chairman agreed with Mr Rozen’s question, “It’s of the utmost importance, isn’t it, for an organisation committed to continuous improvement for bad news to filter up so that it can be addressed?”

“Absolutely,” the chairman said.

The chairman said the organisation is doing a “root cause analysis” to “ensure that this type of incident or any incident for that matter never occurs again”.

The facility’s new CEO agreed with Mr Rozen’s claim there were systemic failings within the facility.

“What is striking about this case… is that it’s not just the problem with the hip wound and it’s not just the problem with the heel wound but we see a pattern here, don’t we, of poor care and at some levels an unwillingness to accept responsibility for that. Do you agree with that?”

“Absolutely, yes,” the CEO replied.

“Our new management team is working hard”

Mr Cohen told HelloCare, “Assisi is a safe, high quality provider of culturally appropriate services to Melbourne’s Itlanian community. We value our families, residents and staff and have communicated with them over the past couple of weeks.

“Our team is focused and continue to work hard delivering high quality services for our residents.

“The board has developed robust clinical governance processes to strengthen oversight. Policies have been updated, staff training organised and relevant equipment purchased. 

“Our new management team is working hard, ensuring open communications with residents and their families to ensure we continue to respond to their needs.”

Image: Royal Commission.

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