When a residential care worker followed the sound of a disabled man’s loud grunts, she was confronted with the sight of him lying face down with the end of his sleeves tied in knots, preventing the use of his hands, and with his sleeves allegedly pinned to the wall.

But the incident that left the care worker “traumatised” has been partly denied by the disability service trusted with caring for the man.

While Enrich+ Trust admitted to tying his sleeves in a bid to restrain him, it denied he was pinned to the wall.

The Health and Disability Commissioner (HDC) has found Enrich+ Trust breached the Code of Health and Disability Services Consumers’ Rights by physically restraining the man.

Deputy Health and Disability Commissioner Rose Wall, in a decision released today, said the man, identified as Mr B, was in his 30s when the event took place last year.

He used his hands to communicate because he was non-verbal. He also had limited vision.

Mr B had been attending Enrich, a charitable organisation that provides support to disabled people, since 2010, taking part in activities programmes several times a week.

A behaviour support plan identified Mr B was known to pinch, punch and kick others.

Enrich’s safety plan, which applied to all those in their care, stated the use of a restraint may be used if it had been approved by the Safe Practice Team.

But Mr B did not have any approved restraints in his behaviour support plan.

Enrich had reported several incidents with Mr B’s behaviour that were “concerning” for the management team, despite his home care team coaching staff on how to handle any challenging behaviour.

Deputy Health and Disability Commissioner Rose Wall found Enrich+ Trust breached the Code of Health and Disability Services Consumers' Rights for its care of the man.

In some instances, Mr B was recorded as having pinched, hit and scratched Enrich staff.

In June 2022, Enrich staff recorded a “spike” in his “aggressive” behaviour and he was added to the internal waitlist for a clinical psychologist review.

The following month, Enrich recorded Mr B arrived to a programme “agitated” and, despite staff trying a variety of methods to comfort him, they decided to call his residential care home to organise someone to collect him.

While a support worker, identified as Ms C, waited for Mr B to be collected she took him into a separate room and said she pulled down his long sleeves over his hands and tied knots at the ends to prevent him from hurting himself or someone else.

Ms C then left the room as another support worker, Mr D, arrived to supervise Mr B and two other clients.

Soon after, Ms F, who worked at Mr B’s residential care home, arrived to collect him.

She told the HDC she entered Enrich but no one was around so she followed the sound of Mr B’s loud grunts.

Staff who were standing in the doorway of the room Mr B was in looked “shocked” to see her and immediately told her, “This may look like a restraint but it’s not”, she alleged.

Ms F described what she saw to the police, stating Mr B was lying on his stomach with his legs dangling off the sofa bed.

She said his long-sleeved jersey-ends were tied in a knot and then tied around a nail in a wall at either end of the sofa bed.

“His left arm was stretched upwards hooked on to a nail and his right arm was stretched downwards hooked on to a nail.

“He was struggling to move around on the sofa. He was very vocal, grunting loudly.”

Ms F alleged the nails and holes in the wall had later disappeared, suggesting to the HDC that the area had been covered with paint.

“This concerns me that they are covering up their [actions] which totally breached [Enrich’s] duty of care towards Mr B,” she claimed to the HDC.

“He is a victim with no justice who cannot see or talk to give his own statement of the abuse he endured.”

Enrich denied there were any nails involved, stating Ms F must have been mistaken.

Ms F said it took about five minutes to untie the knots and once Mr B was released, it took around five to 10 minutes to calm him down.

She stated Mr B was distressed and aggravated, and she “couldn’t reach him emotionally”.

But Ms E, the service lead at Enrich, had a different recollection of events.

She told the HDC she met Ms F at the entrance of Enrich and walked her to the room Mr B was in.

Ms E said she had never seen Ms C use this type of restraint on Mr B before but admitted she should have untied the knots or reprimanded the staff that did it “straight away”.

“I failed. I’m human and we sometimes make mistakes, but I can assure you that I live to protect the ones I serve,” Ms E told the HDC.

She completed an incident report but never mentioned the physical restraining of Mr B. Mr D and Ms C didn’t contribute to the report and there was no evidence that a debrief took place.

Ms E admitted she “stuffed up” by not including the physical restraint in the report but said she had been “crying out for help and no one seemed to be listening” in respect to Mr B’s escalating behaviour.

Ms F told the general manager at the residential care home about the incident a week later.

The general manager said that delay was due to Ms F being “so traumatised” by what she witnessed, stating she appeared to be “very overwhelmed” when speaking about the incident.

Mr B did not return to Enrich.

Police investigated the matter but could find no evidence of criminal offending so took no further action.

Enrich provided an apology to Mr B’s whānau almost a year later and told the HDC it had “learned a lot” from the incident.

Enrich said the Restraint Minimisation policy and the Abuse and Neglect policy have been revised and updated and all support staff must now undergo the Safety Interventions course. Two staff members have also faced disciplinary action.

Enrich will also be monitored by Whaikaha, the funder of its service.

Wall acknowledged the psychological distress these events caused the man and his whānau.

She also acknowledged the restraint was unsafe and put the man at risk of personal injury.

“Enrich had a responsibility to keep the man safe and ensure that he received services of an appropriate standard from suitably trained and supported staff,” Wall said.

“I consider a combination of inadequate care planning in relation to risk management and responding to challenging behaviours, and inadequate staff training and guidance, placed the man in a position of vulnerability, and the care provided to him by Enrich fell short of the accepted standard.”

Emily Moorhouse is a Christchurch-based Open Justice journalist at NZME. She joined NZME in 2022. Before that, she was at the Christchurch Star.