Chair tells royal commission board was responsible for resident’s care failures

A provider has been questioned at this week’s aged care royal commission about its failure to adequately monitor, treat and document a resident throughout her stay and communicate appropriately with relatives including about maggots found in a wound.

On Wednesday, the Royal Commission into Aged Care Quality and Safety featured a case study on the late Annunziata Santoro, who entered Assisi Centre Limited in Melbourne in June 2017 aged 93 with several diagnoses including type 2 diabetes, dementia, chronic pain syndrome and deteriorating eyesight.

The royal commission heard about a series of deficiencies in the care of Ms Santoro, which the providers’s chairman told the inquiry the board took ultimate responsibility for.

Senior Counsel Assisting Peter Rozen outlined deficiencies in Ms Santoro’s care including inadequate monitoring and documentation of Ms Santoro’s ongoing weight loss between March and October 2018 and a lack of communication with her family.

He told the hearing that Ms Santoro was admitted to hospital on 14 July 2018 for surgery for a broken hip after a fall. She returned to the facility three days later but went back to the hospital emergency department on 6 August to have the surgery staples removed because the wound was infected. The hospital discharge report indicated Ms Santoro had a pressure wound on her right heel, he said.

The inquiry heard about the lack of prompt and careful treatment given to Ms Santoro for this pressure injury that included a maggot infestation along with inadequate progression records of the treatment, pain assessment and communication with Ms Santoro’s daughter who held medical power of attorney for her mother.

Anamaria Ng, Ms Santoro’s daughter, said she was not told about the pressure wound until mid-September when she was told it was nothing to worry about.

“I was aware that… a wound specialist had been called in and she was having an x-ray. But again, I was not aware of the significance of the wound,” Ms Ng told the inquiry.

The wound deteriorated significantly around 17 September but was not documented until 3 October and was found with a maggot infestation on 11 October.

Ms Ng said nurse manager Jamuna Jacob and Ms Santoro’s general practitioner Dr Eric Tay informed her the same day that the wound contained eight maggots.

At the time, Ms Ng said Ms Jacob told her and her brother that maggots were used in modern medicine and that she had used them herself.

“[Ms Jacob] was trying to downplay the significance of the whole thing,” she said. “I was appalled that she was essentially not prepared to take any responsibility for what had happened.”

Dr Tay told the inquiry about Ms Jacob being reluctant to inform the family about the discovery of maggots but he said they had to report it.

Dr Tay was questioned about his lack of knowledge about the presence and severity of the wound. He said he wasn’t aware of it until 13 September.

“Often she would have footwear on. I wasn’t, again, alerted to the fact that this is something that had developed,” Dr Tay told the inquiry.

Dr Tay said an assessment by a wound management consultant on 9 October was too late to provide effective treatment for the heel wound and that he didn’t know why it didn’t happen earlier.

Ms Santoro was transferred to a palliative care facility on 23 October and passed away two days later.

CEO, chair respond to failures

Assisi Centre Aged Care interim CEO Paul Cohen said delays in documentation were a concern.

“At a conceptual level, our policy was and is that documentation is accurate and timely,” Mr Cohen told the inquiry.

Mr Cohen, who joined the organisation in May 2019, was questioned by Mr Rozen about why the provider did not provide a spokesperson with personal knowledge of the case as was requested by the commission.

He told the inquiry there were few people left in the organisation with a personal knowledge of the case.

Mr Cohen said he asked Ms Jacobs, who left the organisation in mid-June, about the poor documentation of Ms Santoro’s care.

“She said that sometimes she was too busy to record on at the time, but that she documented it separately on a notepad,” Mr Cohen said.

Mr Cohen said Assisi Centre Aged Care was undergoing changes to address practice deficiencies within the organisation.

“The board have… investigated the matter inasmuch as they were able to with the previous CEO. They’ve acted at a level to remove the CEO and bring… somebody new in,” Mr Cohen said.

“What we’ve been doing is looking systematically at how we improve all aspects that need to be improved, particularly with the focus on… this matter,” he said.

Mr Cohen said the organisation has commenced an investigation to determine the root cause of the failures regarding Ms Santoro’s care.

Assisi Centre Aged Care chairman Donato Smarrelli said the board took responsibility for the poor care provided to Ms Santoro.

“[U]ltimately the board is the ultimate responsible party for all the matters that are here before the commission today,” Mr Smarrelli told the inquiry.

Mr Smarelli said Ms Jacob’s unwillingness to inform Ms Ng and her brother about the presence of maggots did not meet Assisi’s values. “We don’t support that type of conduct within our organisation.”

Mr Smarelli said he regularly saw residents and families at the facility.

“Throughout the 14 years or such that I’ve been there, I make it my business to actually walk the floor. I would go and speak to families and in matters where there are issues that require me to meet family,” Mr Smarelli said.

However, he said the only explanation he could give regarding Ms Santoro’s case was that he relied on the CEO to report on what occurred in the organisation.

“He manages the organisation and reports back to me.  And I rely heavily on… his reporting,” Mr Smarelli said.

The hearing continues today in Darwin and in Carins until next Wednesday.

To stay up to date on the latest about the Royal Commission into Aged Care and Quality go to our special coverage. We will also be issuing regular Royal Commission Roundup reports which you’ll receive in addition to your weekly e-newsletters.

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