An elderly woman in a rest home who required long-term hospital care was neglected so much that her wounds were allowed to progress to the point where they had maggots.
The woman did not receive appropriate assessment and care of her numerous wounds while in the care of Care Alliance Ltd, and died about six months later, the Health and Disability Commissioner has found.
Deputy Commissioner Rose Wall's decision came after a woman, only identified as Mrs B, laid a complaint against the rest home in 2015.
The elderly woman identified as Ms A was discharged from a public hospital to the rest home, and had "high and complex" needs, having multiple existing ulcers when she was admitted.
In the report, it's highlighted the woman developed further wounds after being admitted to the rest home.
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According to the commissioner's report, her wounds were allowed to progress to a point that they had become significantly infected - some of which had maggots.
After about six months, the woman became increasingly unwell and was readmitted to public hospital. She died after being diagnosed with sepsis.
The woman experienced "considerable pain" and there was no evidence she was provided with pain relief.
"Her condition deteriorated which could have been avoided had her pain been managed more effectively," Wall said.
The commissioner found that by neglecting the woman in such a way, the rest home was found in breach of the Code of Health and Disability Services Consumers' Rights.
She also found the rest home did not have important information relevant to the woman's care, so it could be assessed as required.
"It was recommended that Care Alliance Limited provide a written apology to Ms A's family," Wall says.
In 2017, Care Alliance sold the rest home to a new owner.