A damning review of the care of a great-grandmother has found the 99-year-old was chemically restrained in her final days and not administered end-of-life medicines until 20 minutes before her death.
Hazel Neal died at the Ascott Gardens aged care home at Orange in central-west New South Wales in December 2020, from septic shock, acute renal failure, and a urinary tract infection.
The home is run by the not-for-profit United Protestants Association (UPA).
Her granddaughter, Suzanne Kerwick, said her grandmother had died delirious and in pain.
"She was moaning, groaning, she really had no dignity. She was crawling around the floor half exposed, covered in carpet burns and bruises," Ms Kerwick said.
"It was just a terrible, terrible end to a lovely long life, and it's just something our family will never ever forget.
Now, the Aged Care Quality and Safety Commission has found Mrs Neal's care in her final three weeks was "inadequate" and had "significant departures from expected clinical practice in relevant areas of care".
The commission's review, seen by the ABC, identified a series of problems.
Mrs Neal had previously been hospitalised with a urinary tract infection and delirium in October 2020.
The commission found that, despite this, when she fell sick two months later with similar symptoms the home failed to call a doctor or assess the cause of her illness, and there was not any evidence of trying non-pharmacological strategies to treat her delirium.
Instead, staff sought anti-psychotic medication for Mrs Neal, the commission found.
Before using psychotropic medications such as anti-psychotics, the Aged Care Act requires all other behaviour management interventions to be tried.
"Under the heading 'Alternative Interventions', the person completing the form has simply written 'all failed'," the report read.
"This is not reasonable as it gives no indication as to what non-pharmacological interventions have been trialled when attempting to manage Mrs Neal's agitated behaviours.
'Not reasonable' delay in pain relief
The review found Mrs Neal's family had requested a GP visit for days prior to her death, but none was organised.
On December 21, Mrs Neal began to deteriorate further, with staff noting she had a low temperature and slow respiratory rate, although no other observations were recorded.
Mrs Neal did not receive any of her regular medicines, including pain relief.
By 1pm, staff noted she was "distressed", and a GP was contacted.
By 1:45pm, he had prescribed end-of-life medicines, but they were not administered until 2:30pm.
Twenty minutes later Mrs Neal died.
The review found the delay in administering the medicine was "not reasonable" and "anticipatory orders for end-of-life medicines should have been in place at the time it was evident that Mrs Neal's condition was deteriorating".
Ms Kerwick said she and her family felt her grandmother's death had been preventable.
"If she'd received the appropriate treatment, which was just something as simple as some antibiotics, I'm sure she would have still been alive," she said.
While the review did not go so far as to say Mrs Neal's death was preventable, it did note "that urinary sepsis can develop quickly and requires early administration of antibiotics to reduce the incidence of mortality".
The review found that in the two days before Mrs Neal died, "staff only sought orders for increased antipsychotic medication and did not consider other factors such as acute illness or unmet care needs as a contributing factor in her changed behaviours.
"There is also no evidence that any vital observations were undertaken on these days or that staff made requests for immediate, in person GP review of her condition."
Home sanctioned
The Ascott Gardens aged care home was issued a non-compliance notice in December 2021 for failing to meet standards related to personal care and clinical care.
It has slipped to a two-star rating on the federal government's My Aged Care website.
Ms Kerwick said that was of little comfort to her family.
"Nothing seems to change."
In a statement, the Aged Care Quality and Safety Commission declined to comment on the review due to privacy considerations.
But, it said, when issues were identified at a service, "we take action that is appropriate and proportionate".
The home has been subject to a non-compliance notice since December 24, 2021 and the report of a follow-up audit conducted earlier this month is expected to be published in June.
In a statement, Ascott Gardens said a draft report from that audit showed it had returned to full compliance with clinical care standards.
It said the home had repeatedly met with and offered "sincerest condolences" to Mrs Neal's family.
The home did not address questions about whether it would apologise, the finding of the use of chemical restraint, or the delay in providing medicines as Mrs Neal was dying.
