A disabled elderly man who choked on his food after nurses failed to follow his clearly set out dietary plan died in an “unfamiliar environment, isolated” from his caregivers.

Now, Waitematā DHB (now Te Whatu Ora Waitematā) has been criticised for failing to provide the man with reasonable care and skill by the healthcare watchdog.

The man, in his eighties who is only referred to as Mr A, was born with intellectual disabilities and had lived in residential care for the majority of his life, relying on caregivers for his day-to-day living.

Mr A also had severe language impairment and minimal communicative capacity. He was at risk of choking and aspiration from eating and drinking, requiring him to have a comprehensive dietary plan.

The dietary plan stated he was only to be given pureed or liquid foods and had to be supervised at all times while eating.

The dietary plan read: “I am at risk of choking and aspiration from eating and drinking.

“I require full supervision from staff during the whole mealtime.”

In 2021 Mr A was admitted to Waitakere Hospital from his care facility with a chest and urinary infection.

Rose Wall, Deputy Health and Disability Commissioner found the man was not provided with proper care and skill.

A support staff member accompanied Mr A to ensure hospital staff were informed of his medical history and dietary plan, which was recorded in his medical notes.

At about 3pm that afternoon, an ED nurse recorded that Mr A’s past medical history included “severe intellectual impairment”, noting there were a “few random words”.

Despite this, the ED nurse assessed Mr A as being at “no risk” of falling and being “independent” for moving and handling with a “normal” cognitive/mental state.

Over the next two days, Mr A was transferred from an assessment and diagnostic unit to a general medical ward with no mention of his dietary plan recorded in the handover form, however, some nurses’ notes stated he needed “pureed food and thickened fluid”.

On the second day, a service manager at Mr A’s care facility came to visit him and reminded the nurses of his support needs, particularly with eating and drinking.

A nursing student completed a transfer form for Mr A, but this did not contain any information about his dietary plan or feeding requirements. A “soft mechanical diet” was also ordered for Mr A instead of a pureed diet.

A soft mechanical diet is not smooth in consistency and can contain lumps, whereas a pureed diet should contain no lumps and require no chewing.

On the third day, the care facility service manager visited Mr A again and noticed he had been given normal water. He reminded the nursing staff his water needed to be thickened.

Later that day Mr A was transferred to another ward with no handover documentation being recorded.

On day five, Mr A was noted as “moaning and groaning” and pushing staff away, making it difficult for blood testing to be done.

At around 6pm Mr A was given dinner by a healthcare assistant. He sat Mr A in an upright position and set a tray of meat and vegetables in front of him.

The healthcare assistant then left Mr A to hand out the rest of the meals, telling a nurse he would return to feed him.

The healthcare assistant later said he was not aware Mr A required constant supervision during his meals or that he had a risk of choking.

About 20 minutes later a nurse found Mr A struggling and looking like he was trying to cough. She found he had chicken and vegetables in his mouth and hit the emergency bell to call for a doctor.

An emergency medical team responded but Mr A soon became pale and unresponsive. He was not for resuscitation and was pronounced dead at 6.33pm.

A coroner ruled the preliminary cause of Mr A’s death was due to an “aspiration event secondary to a food bolus, with respiratory arrest.”

Te Whatu Ora accepted that the information in relation to Mr A’s dietary plan was not handed over adequately between staff or documented clearly.

Te Whatu Ora stated that the responsibility for ensuring patients receive appropriate food and fluid at mealtimes sits with the nursing staff and the healthcare assistant who gave Mr A his final meal was not provided with this information.

Deputy Health and Disability Commissioner, Rose Wall found hospital staff did not give sufficient attention to a “significantly disabled” patient who was unwell in an “unfamiliar environment, isolated” from his caregivers.

“He was unable to communicate his needs to the various staff caring for him.

“This case reinforces the significance of clear communication. It is the cornerstone of providing safe and effective care to patients, even more so when the patient is particularly vulnerable and reliant on others to keep them safe,” Wall said.

A number of changes have been made since the events, including a review of handover documentation, which now includes a field to record patients’ dietary needs.

The wards that were involved in Mr A’s care have also been asked to ensure that dietary requirements are part of the shift handover, and the wards must ensure that the patient information board correctly reflects both the patient’s individual dietary needs and any assistance they may require.

Wall made several recommendations, which included that the DHB provide training to all relevant staff on the handover processes and the handover practice expectations, and on the importance of the dietary requirements of patients, so that they are aware of the risks of failing to adhere to any dietary plans.

Te Whatu Ora Waitematā will also be referred to the Director of Proceedings to decide if any proceedings should be taken.

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