InDaily revealed the case last year, after the man was rushed to hospital from the Transition to Home (T2H) care service run by the Department of Human Services (DHS) at Hampstead Rehabilitation Centre.

Paramedics and doctors were so concerned about his condition they lodged complaints about his alleged neglect.

After a lengthy investigation, the independent health watchdog this morning released his findings, including “failings in hygiene, wound care and weight management and how they led to a situation that should have been avoided”.

Health and Community Services Complaints Commissioner Associate Professor Grant Davies condemned “poor communication” by those in charge of the man’s care and a lack of support services.

He has made a series of recommendations to improve care for other vulnerable South Australians and demanded DHS apologise to the man and his family.

T2H is a step-down facility for people with disabilities who have been discharged from a long stay in hospital and are awaiting more permanent accommodation.

The man was admitted to the service after being discharged from an un-named regional SA Health hospital, but the Commissioner found he should not have been sent there because his needs were too high and the right supports were not in place.

The case has similarities to that of Ann Marie Smith, who died in hospital in 2020 of septic shock and organ failure after allegedly being left to sit in a cane chair for a year.

“I am disappointed that the care of a consumer living with a disability is again under scrutiny,” Davies said.

In his report, Davies said the SA Ambulance Service (SAAS) crew noted concerns about the care of the man – referred to as Mr D – including “that he had an infected pressure wound, that he was wearing dirty clothing and that he had malodourous body odour”.

Davies said SAAS received a triple zero call on May 31 regarding Mr D “who had increased drowsiness and was not responsive”.

On arrival, they found the man with an infected pressure wound, with patient clinical records stating: “SAAS staff found patient with dirty clothing (had not been changed for a few days). Malodourous body odour and poor personal hygiene due to the negligence of carers.”

“Patient’s case worker and sister report patient has been found in this state (left in faeces and urine (for) prolonged periods of time, with a dirty moist towel over infected wound site),” the notes said.

“SAAS staff also found the wound care of the RN (registered nurse) to be neglectful and subpar…”

Davies said SAAS later provided further information including that:

• Mr D “appeared to be malnourished with a large pressure wound on his jaw”.
• Mr D’s “clothing and underwear were soiled (and) it did not appear as though he had been washed recently with malodourous body odour”.
• The (ambulance) crew were “led to believe that the wound had not been exposed or irrigated on the last visit 3 days prior to SAAS attendance. On the day of SAAS attendance the RN had not fully exposed the site and placed only a saline soaked dressing combine over it.”

In his findings, Davies said the man weighed 57 kilograms – “below his identified healthy weight range” – when he was weighed at the Royal Adelaide Hospital on June 3.

“When SAAS officers attended T2H on 31 May 2021, they thought Mr D appeared to be malnourished,” he said.

“DHS acknowledges that T2H could have done more to monitor Mr D’s weight and agrees that his weight loss contributed to him being a high risk of malnutrition.”

Davies also found that T2H “failed to properly understand and assess Mr D’s health and needs and implement a care plan which identified and incorporated things such as mobility, hygiene, nutrition and hydration and pressure area care”.

He said it was “not appropriate” for the man to be admitted to T2H “as the level of his disabilities meant that he required total assistance in the areas meal preparation, feeding, toileting/continence, bathing, dressing, grooming, medication, bed linen, transfer and pressure area care which T2H demonstrated that it was not able to fully meet”.

The Commissioner made 13 recommendations including that T2H “apologise to the man and his family for the inadequate care he received”.

He also recommended that hygiene and care be assessed on admission to T2H for all patients, and checked regularly throughout their stay.

In addition, he called for T2H to establish a “Health Monitor” to conduct “regular and documented health and welfare checks of each person admitted to T2H to ensure they are being adequately cared for”.

The findings have prompted an immediate apology from the Premier, Health Minister and head of the Human Services Department, who have all promised to fix the problems.

Premier Steven Marshall said “there’s no doubt that we have let this patient down and we apologise for that”.

“I unreservedly apologise to this patient and his family,” he told reporters this afternoon.

“We have fallen well short of the standard which is acceptable and we will take action to ensure this never happens again.”

Marshall said the Government would implement “every single one” of the Commissioner’s recommendations.

“And if there’s need for overall system change then that will be put into place,” he said.

“There are already things identified in this report which I think will lead to improved outcomes for all patients that are in that transitional accommodation.”

In a statement, DHS chief executive Lois Boswell said: “The Department of Human Services (DHS) has accepted the Commissioner’s findings and is genuinely sorry that the client did not receive the level of support and care expected.”

“DHS has formally apologised to the client and their family and accepts it should have been more proactive in ensuring the external NDIS nursing agency attended to provide the wound care required,” she said.

Boswell said the department was already implementing the Commissioner’s recommendations, “including a new management structure and an onsite Team Leader who is authorised to take any action appropriate to ensure clients receive the care they need”.

“DHS encourages clients and their families to immediately raise any concerns they may have to ensure the T2H service continually improves and meets required standards,” she said.

Health Minister Stephen Wade rejected suggestions the case had similarities to the Ann Marie Smith matter.

“This is a world of difference from Ann Marie Smith,” he told reporters.

“We’ve got a situation where Ann Marie Smith’s former carer is before the courts for criminal neglect – months and months of neglect of a client. Completely different in relation to Mr D.

“This gentleman was receiving daily personal care, he was receiving daily baths, he was receiving pads for his incontinence. The situation was not in relation to his personal care.

“This unit failed to, if you like, identify his medical needs. It’s not a medical facility.

“What the Commissioner’s report has highlighted is the Department of Human Services needs to make sure they’ve got line of sight of the medical needs of their clients, not just the personal care of these clients. The Department of Human Services completely acknowledges that and is in the process of fixing it.”

Asked to respond to excerpts from the Commissioner’s report detailing the man’s infected wound, severe body odour, dirty clothes and that he’d been left to sit in faeces and urine, Wade said: “My understanding is that the client did receive daily baths and was receiving pads.”

“There were a number of issues that were raised but my understanding is the key issue was making sure that people get the medical support they need when they’re in a facility like T2H,” he said.

“Of course we want to continue to provide transitional facilities, but in the context of transitional facilities we need to be aware of the fact that clients might have ongoing health needs.”

Asked if he would apologise to the man and his family, Wade said “of course”.

“We always apologise to our clients where let them down, where we fail to deliver the quality of care that they need but the best way to show respect to people when we do let them down is to make sure we take every step possible to make sure it doesn’t happen again and that’s exactly what we’re doing,” he said.

Opposition health spokesperson Chris Picton said “this is a shocking case and the details from the SA Ambulance report on this elderly man are just appalling”.

“Based on the Premier’s own words and expectations, Health Minister Stephen Wade and Human Services Minister Michelle Lensink must take responsibility for this appalling case,” he said.

“Hampstead is an SA Government public hospital site and the fact that a patient was found malnourished, ‘left in faeces and urine’ and the care was ‘neglectful and subpar’ is a shameful indictment upon how this government treats people in its care.”

Opposition human services spokesperson Nat Cook said this “terrible incident” was a “direct consequence” of Lensink’s “refusal to advocate and intervene in this crisis of housing”.

“As Minister for Disability and Housing, Minister Lensink simply needs to have a conversation with herself in order to put strategies in place that would stop people with disability languishing for months and sometimes years in the health system without appropriate supports,” she said.

In a statement a spokesperson for Lensink said “unlike the former Labor Government who presided over a culture of cover-ups and blame shifting, we have a culture of reporting and taking action”.

“On this occasion T2H failed the client and did not meet the required benchmarks for support and care,” the spokesperson said.

“As recommended by the Commissioner, DHS has immediately actioned new processes and systems to ensure the quality of care at the T2H service meets required standards.”