A 99-year-old dementia patient died after being assaulted in his rest home bedroom by another resident suffering from dementia, a coroner has found.
Leonard Ralph Hewgill suffered a head injury in the attack at the Ryman Healthcare-run Hilda Ross Retirement Village in Hamilton and died in hospital three days later.
Coroner Louella Dunn's report into Hewgill's death in October 2018 was released to RNZ.
Coroner Dunn said Hewgill was a resident at Hilda Ross Special Care Unit, a 40-bedroom unit offering specialist dementia care.
He had lived there since 2017 and was well loved and regularly visited by his family, she said.
On the evening of October 3 2018 Hewgill was attacked in his bedroom by another resident, Ike Cowley, who was then 71 years of age and was suffering from Parkinson-related dementia.
Cowley entered Hewgill's room around 8pm and Hewgill was heard telling him to leave, Coroner Dunn said.
"Subsequent to that, the emergency alarm in Leonard's room was activated by a staff member who attended. Leonard was observed by the care worker lying on his bed in his bedroom and bleeding from his ear. Mr Cowley was found in Leonard's bedroom standing over Leonard and he was visibly agitated," she said.
"Mr Cowley refused to comply with care workers' instructions and continued to be agitated and angry. He made a number of threats to Leonard including 'I'm going to kill him' and 'let him die, let him die'. Leonard appeared to be unconscious but responded to assistance from care workers and told the care workers 'he's hitting me'.
Coroner Dunn said staff intervened in the assault and Cowley left Hewgill's bedroom, however he remained agitated.
Despite his demeanour, care workers and staff at the unit did not take any steps to keep Cowley under their control or restrain him, and Cowley went on to assault another resident down the corridor, she said.
Hewgill was taken to Waikato Hospital and died of his injuries on October 6.
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Police investigated the assault and subsequently charged Cowley with the manslaughter of Hewgill and wounding with intent to injure, which related to the assault of the other resident the same night.
Due to Cowley's dementia, he was found unfit to stand trial and was dealt with under the Criminal Procedure (Mentally Impaired Persons) Act 2003.
Coroner Dunn said Cowley was released and the criminal charges were stayed.
She said an inquiry was opened as Hewgill's family advised her of their concerns regarding the care management of residents with dementia and in particular residents suffering from dementia assaulting other residents in the facility.
As part of the Coroner's inquiry she received reports from Hilda Ross, the Health and Disability Commissioner, and independent reports from Ruth Thomas (DHB Regional Dementia Nurse Advisor) and Dr Jane Casey (Consultant Psychiatrist and Psychogeriatrician).
Coroner Dunn said Cowley was admitted to the Hilda Ross Special Care Unit in 2016. His transfer notes stated he was at risk of falls, wandering, exit seeking and absconding.
As his mental health deteriorated he had become aggressive and demanding, behaviour that was foreign to him prior to his illness, she said.
During Cowley's time at Hilda Ross there were 54 reported incidents of challenging behaviour noted for him, including exhibited agitation and physical aggression.
A significant proportion of the incidents were targeting other residents while others targeted staff.
Coroner Dunn said Hewgill's death revealed deficits in Hilda Ross' processes managing residents with challenging behaviours.
This included a lack of meaningful documentation to identify a resident's challenging behaviour in a manner where staff could readily recognise that behaviour and its triggers. She said staff were also not provided adequate information as to how to deescalate that behaviour.
"It is disappointing that Mr Cowley's repeated acts of aggression while a resident in the SCU were not properly identified and addressed by Hilda Ross," Coroner Dunn said.
"It seems evident from the two independent reports and the evidence provided to me that Mr Cowley was a potential risk to both residents and staff. He required a clear and comprehensive plan to ensure challenging acts could be avoided or if occurred that they could be quickly deescalated.
"I acknowledge that care of residents suffering from dementia can be challenging for organisations and their staff. However, the rates of dementia are on the rise within the aged New Zealand population. The care provided by Hilda Ross is paid care, residents are often vulnerable, and families place their trust in the residential care provider."
Coroner Dunn's recommendations to Ryman Healthcare included strengthening documentation processes and training programmes for team members to help them recognise and respond to resident distress.
She said the company submitted they had learnt from what happened and had improved their processes.
Ryman Healthcare chief operating officer Marsha Cadman said Ryman remained deeply saddened by Hewgill's death.
"After the passing of Mr Hewgill, we expressed our sincere condolences to his family and provided ongoing support to them, and to all involved, staying in close contact throughout our internal review and the subsequent police process. Following the incident, we immediately launched an investigation, with two independent experts," she said.
"This resulted in changes across all our dementia care units, reinforcing our commitment to providing safe, respectful, high-quality care. All of the changes and coroner's recommendations were implemented by 2019.
"Our commitment to upholding the safety and dignity of every resident remains unwavering."
Coroner Dunn said Hewgill's family were seeking a national legally enforceable policy regarding care management of aggressive residents with dementia.
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