Health watchdog lists ‘significant gaps’ in Norma Palmer’s care at Regis Birkdale

The national health watchdog has listed ‘significant’ gaps in the care of a Queensland grandmother who died while a resident at a bayside aged care facility. Warning: Graphic images

Norma Palmer was 89 when she died from a wound on her leg according to a coroner’s report.

The national health watchdog has listed “significant” gaps in the care and treatment of an elderly woman who died while a resident at a bayside aged care facility.

Grandmother Norma Palmer died when a wound on her leg rotted exposing her ankle bone and after the skin on her back was left red raw.

She had been a resident of the up-market Regis Birkdale aged care facility for nearly 10 months, when she was rushed to hospital in July last year and died three days later.

The Aged Care Quality and Safety Commission, set up to protect people receiving aged care, told Mrs Palmer’s grieving family that Regis Birkdale had acknowledged they did not consistently provide a satisfactory level of care to Mrs Palmer.

ACQSC complaints officer Melissa Hilless told the family that a preliminary internal investigation had found “significant gaps” in pain management and wound management.

Ms Hilless said Regis Birkdale had established a Continuous Improvement Plan to address those flaws.

Regis Birkdale, where Norma Palmer was a resident for about 10 months and where inquiries have found ‘gaps’ in her care.

However, Ms Hilless said the investigation was still ongoing and some of the internal recommendations were yet to be implemented.

The gaps in processes at the facility included the lack of painkillers; staff not understanding their role in escalating concerns when the wound started getting worse; and delays in getting medicine and antibiotics for Mrs Palmer.

Junior staff providing information to senior clinical staff “may have contributed to inadequate information being provided” to external clinicians regarding care and management of wounds.

The claims were made in a January email to Mrs Palmer’s granddaughter Alana Hewett, after a coroner’s report in July last year.

The email from Ms Hilless outlined six areas that Regis Birkdale had identified as “gaps in care”.

Wound management; skin assessment and pressure injury prevention and management; pain management; communication and consultation with family; identification, escalation and monitoring of clinical deterioration; and care planning, communication and governance, were listed.

“Wounds were not always reviewed by wound specialists. Mrs Palmer’s deteriorating wound should have been escalated to a wound specialist sooner than when it occurred on 12 July 2020,” Ms Hilless wrote in her email.

Norma Palmer’s leg was rotting, who was not given pain killers and she had not been sent to a wound care specialist until three days before her death.

“Wound reviews were not consistently monitored. GP reviews were not always sufficiently detailed regarding wound management directives.

“Wound care pathways were not followed by staff, including dressing changes and reviews.

“Lack of senior clinical staff completing complex wound reviews and dressings.

“The majority of wound care was completed by enrolled nurses.

“Wound photography did not meet expected practice, as photos were not clear, measurement not shown and not always taken to support ongoing wound progress documentation.”

Processes are also being put in place at the facility to improve communication between GPs and staff.

Mrs Palmer’s GP listed her back condition as being Steven-Johnsons Syndrome, a rare skin condition triggered by a medicine, adverse reaction or infection.

The GP considered it was triggered by Keflex and complicated by other health issues.

However, there was no evidence that staff were made aware of, or received education, about the rare condition.

Another “gap” was the lack of painkillers used during wound management even though Mrs Palmer showed signs of significant pain.

According to a record of drugs administered, Mrs Palmer was not prescribed any painkillers.

ACQSC said a clinical manager would now refer all wounds of concern directly to external wound consultants, such as Care Pact, and would not need to wait for the consent or referral from a GP.

Norma Palmer with her daughter Leanne Hewett.

All wounds would be photographed using a new camera to be bought for the centre and a clinical manager would review all wounds each week.

An external wound specialist also educated nine staff about wound care and processes in July, when an audit of wound management was also conducted at the facility.

Further education on wound care and management was given to 10 staff in August, when eight residents with concerning wounds were also reviewed.

ACQSC found in January that education had not yet been provided to all registered staff, and it was unclear if the camera had been bought.

Mrs Palmer’s GP provided a report to the coroner’s court, which raised concerns about processes in place to ensure a resident’s care was well co-ordinated and that critical information was provided to all parties.

The GP was referred to Australian Health Practitioner Regulation Agency, which has not taken any action over the doctor.

Regis communications manager Kate Tyrrell said the case remained open with the Aged Care Quality and Safety Commission within the complex resolution team.

It is the second Regis aged care facility to come under scrutiny by the federal aged care regulator.

In February, the Aged Care Quality and Safety Commission found there was an “immediate and severe risk to the health, safety or wellbeing of residents” at Regis Nedland in Western Australia.

It was the second such finding in 14 months and followed allegations of neglect from two families.