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Warning: This story details elder abuse that some may find disturbing.
Health staff missed opportunities to help an elderly Christchurch man with advanced dementia who was being abused by his son, the health watchdog has found.
Norman Lee, 90, died weeks after police found him on a urine-stained mattress wearing adult nappies under a wetsuit in a dark, cold room in 2020.
His son, David Lee, had locked him in the room for up to 16 hours a day in conditions a judge likened to torture.
David Lee and another person were jailed in 2022 for abuse and neglect and for stealing more than $220,000 that was spent on cars, entertainment systems, scooters and holidays.
In findings released in May, coroner Mary-Anne Borrowdale stated the cause of Norman Lee's death was pneumonia and severe heart disease with a background of frailty and dementia and a context of elder neglect as a contributing factor.
In a case study published on Monday, the Health and Disability Commission (HDC) highlighted "systemic failures across services in recognising and responding to elder abuse risks, particularly where care occurs within a family setting".
Individuals are anonymised in the report but RNZ has confirmed the case relates to Norman Lee's care.
The commission said visiting health staff failed to escalate concerns about abuse.
The HDC pointed to Health New Zealand's poor record-keeping and case management continuity, lack of adequate staff support and supervision and gaps in processes for identifying and escalating elder abuse concerns.
"These failures contributed to missed opportunities to detect and respond to potential neglect," it said.
The HDC said HealthCare NZ provided regular weekly home domestic support, 15 minutes of daily support for meal preparation and twice-weekly personal care support for hygiene. Norman Lee also received support and oversight from Older Persons Mental Health at Health NZ.
"Three instances of concerns about possible neglect were raised in 2018 and 2019 and on each occasion initial inquiries found no evidence of abuse. The concerns raised were closed without further follow-up by any agency," the HDC said.
Workers failed to escalate concerns
During this period none of the individual workers involved in Norman Lee's care escalated concerns about abuse, and to the extent they queried practices in the home they received assurances from the family about care arrangements.
"In June 2020, after a hospital admission, a home visit by a Health New Zealand social worker revealed concerning living conditions, including restrictive and unusual measures (e.g. locked spaces, environmental controls outside the bedroom, camera monitoring, and use of a wetsuit at night). These issues were not previously escalated despite multiple service providers being involved," the report said.
The HDC found Health NZ and HealthCare NZ breached the code of health and disability services consumers' rights.
The commission said Health NZ failed to provide services with reasonable care and skill because of systemic issues.
The HDC recommended both organisations provide a formal apology and improve their processes.
"The commissioner acknowledged improvements implemented by Health NZ and HealthCare NZ in the six years that had passed since the events in response to the issues identified in this investigation," the report said.
Recommendations 'addressed and implemented'
A Health NZ spokesperson said the agency acknowledged the commission's findings.
"In line with our commitment to providing safe, high-quality care, all recommendations have been addressed and implemented," they said.
"Health New Zealand extends our deepest apologies to the family for their loss and recognise the profound impact of his death in 2020."
HeathCare NZ declined to comment.
Coroner Borrowdale said she was satisfied the criminal and other investigations into the "tragic and horrific" case established the facts and made a coronial inquiry unnecessary.
