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Aged Care Provider Breaches Code For Failure To Manage Pressure Injury.

In a report released today, Aged Care Commissioner Carolyn Cooper found Mayfair Lifecare (2008) Limited breached the Code of Health and Disability Services Consumers’ Rights (the Code) for their care of a man in his eighties.

The man was in hospital level care at Mayfair following a recent stroke which had affected his mobility and ability to communicate. Despite care plans being in place to manage the man’s stroke symptoms, adequate care was not taken to manage his pressure injury.

Ms Cooper found Mayfair breached Right 4(1), which gives consumers the right to have services provided with reasonable care and skill.

Three shortcomings in care were identified in the breach. Several wound charts were in place but it was unclear which chart staff were following, which affected the coordination of wound care. The man did not regularly receive his prescribed pain relief prior to having his wound dressed (despite clear instructions in the Medi-Map medication system). Staff did not record on the man’s pressure care chart the times he was repositioned.

"I am critical that a vulnerable resident who could not verbalise when he was in pain was not given his morphine as prescribed. This meant he likely had to endure painful dressing changes," Ms Cooper said.

"I am also critical that when the man’s daughter expressed concerns about her father’s pain and asked for him to be given pain relief, at times this was not given."

Ms Cooper was also critical that the staff did not adhere to the medication management policy when recording when morphine was given, including the rationale for its administration and its effect.

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"In my view, this raises concerns about staff adherence to policies and medication instructions, and communication with residents’ advocates," she said.

Ms Cooper acknowledged the distress the event had caused the man’s family and offered her condolences to them for the loss of their loved one.

Ms Cooper made a number of recommendations to Mayfair, including that they provide a written apology to the man’s family for the issues identified in this report and that they conduct random audits of staff compliance for ten residents over three months to check adherence to the pain, wound and pressure injury management policies.

Mayfair accepted the report’s recommendations and said they had continued to review their processes to ensure learnings from this complaint are reflected in the standard of care delivered.


The full report of this case can be viewed on HDC’s website - see HDC's ' Latest Decisions'.

Names have been removed from the report to protect privacy of the individuals involved in this case.

The Commissioner will usually name providers and public hospitals found in breach of the Code unless it would not be in the public interest or would unfairly compromise the privacy interests of an individual provider or a consumer. More information for the media, including HDC’s naming policy and why we don't comment on complaints, can be found on our website here.

HDC promotes and protects the rights of people using health and disability services as set out in the Code of Health and Disability Services Consumers' Rights (the Code).

In 2022/23 HDC made 592 quality improvement recommendations to individual complaints and we have a high compliance rate of around 96%.

Read our latest Annual Report 2023

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