A charitable organisation which provides support programmes for disabled people has been criticised after one of its staff members pulled the ends of the sleeves of a disabled man's jersey over his hands and tied them in knots.
Deputy Health and Disability Commissioner Rose Wall said Enrich+ had failed to ensure the safety of both its staff and the man over the incident on July 25 last year. Wall also said the care Enrich provided to the man "fell short of the accepted standard".
The man (Mr B), who was aged in his 30s at the time of the incident, has limited vision and epilepsy. He is also non-verbal. He lives in a residential service but regularly attended Enrich's day activity programme.
He communicates with his hands and by using body language. Wall said he understands basic commands in te reo and English.
Wall said a residential service staff member (Ms F) had gone to collect the man after being called by one of Enrich's staff as he was unsettled.
When he had arrived at the programme around 1.5 hours earlier he was "already in an agitated state" and numerous methods by Enrich's staff to calm him were unsuccessful.
When Ms F arrived she said she found Mr B lying face down on a sofa bed in Enrich's sensory room, the ends of his sleeves tied in knots. Wall said the restraint could have been in place for around 30 minutes.
The support worker (Ms C) who had tied the knots in his sleeves told the HDC she had done so "not in a negative sense but in a more positive sense for the safety of himself, myself and anyone else".
Enrich's staff also said Mr B had chosen to lie face down on the bed.
Wall noted in her report Mr B's behavioural support plan said he was known to pinch, scratch, kick and punch others when he was agitated and would also hurt himself.
There was nothing in his support plan about approved restraints, Wall said.
Staff had been told the month before when he became physically aggressive he should be guided to a safe place to calm down and staff should keep their distance. This was because between March and July there had been six incidents where Mr B had been aggressive.
Enrich told the HDC it was working with Mr B's residential service to identify more steps which could be taken to keep him and others safe.
An incident report was filled out by an Enrich manager over the July 25 events but it did not mention the unauthorised physical restraint Mr B had been put in.
Ms F did not report the incident to a manager until August 1, Wall noted. It should have been done no later than 24 hours afterwards.
The residential service told Mr B's sister about the incident the next day. She later complained to the HDC.
On August 3, the chief executives of both the residential service and Enrich were told of the incident. Enrich later carried out an internal review and an incident investigation report was completed on August 8. Police were contacted on August 9 but after a visit at the end of October found there had been no criminal offending.
The Ministry of Disabled People (Whaikaha) commissioned an independent audit of Enrich and its report was completed on December 1. It told the HDC it is monitoring Enrich. It recommended Enrich develop standalone policies and procedures around abuse and neglect, restraints, provide staff with more training and develop a process to ensure incidents are reported accurately.
Enrich gave Mr B's whānau a formal apology in June this year.
Wall concluded the restraint used on Mr B was "unauthorised and inappropriate".
"Restraining Mr B in such a manner placed him in an unsafe position, and from his reaction to the release of the knots... it is fair to assume that he found the event profoundly distressing," she said.
Wall said Enrich bears "primary responsibility" for the July 25 events. She also said it failed to ensure the safety of its staff and Mr B due to "inadequate training".
"I consider that a combination of inadequate care planning in relation to risk management, and inadequate staff training and guidance, placed Mr B in a position of vulnerability, and that the care provided to him by Enrich fell short of the accepted standard."
Wall recommended Enrich report to the HDC within six months regarding its progress on Whaikaha's recommendations and that several of its staff members provide a formal written apology to Mr B and his whānau.
Enrich Group Responds
In a statement provided to 1News on Tuesday, Enrich Group chief executive Karen Scott said Enrich Group provided a "formal written apology" to the client and his family in June, as did staff members involved.
She said this included revising and updating the restraint minimisation policy and the abuse and neglect policy.
“Our thoughts go out to our staff who are still distraught months after this took place. It is not who they are. They have apologised and we are working actively with them and other staff to use this case as a basis for developing education and training," Scott said.
She said the organisation let down the client and "fell short" of the high standards they have set, but had taken lessons from the Health and Disability Commissioner's investigation.
She said this is the first complaint since the organisation was established 32 years ago. Enrich Group has 580 clients across several sites.
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