Norman Lee was kept in a dark, filthy bedroom, isolated and neglected by those who should have been there for him in his final months.
His adopted son would lock dementia-addled Lee in the room for up to 16 hours a day, forcing him into a wetsuit to catch his own urine and faeces.
After 90-year-old Lee relieved himself in the wetsuit, he would bang on the door, calling for help for up to an hour at a time.
But his son never came. Lee died after months of maltreatment.
David Lee was eventually jailed for six years for treatment of his elderly father that was described as “akin to torture”.
Another person with name suppression received a sentence of two years and seven months for their role in keeping Lee in unhealthy conditions.
It was found that their offending occurred over an unclear period, but no less than 11 months.
Coroner Mary-Anne Borrowdale opened an inquiry five days after Lee’s death in July 2020, but was not content to complete it without understanding why a social worker and carers had not reported concerns.
Now, she has released the inquiry findings, which reveal criticisms of those tasked with caring for Lee.
According to today’s findings, the Health and Disability Commissioner concluded Health NZ’s “systematic failing cumulatively contributed” to the substandard care Lee received, “rather than individual staff actions or inactions”.
The findings show differing accounts from both authorities about the events leading up to his death.
‘Shocking conditions’
The findings stated that when police uplifted Lee from his Christchurch home on June 23, 2020, they made shocking discoveries about his living conditions.
His bedroom was locked from the outside by a deadbolt, and he was found in bed in the darkness with an overwhelming smell of faeces.
His mattress was badly stained, and he was wearing a wetsuit over an adult nappy.
The wetsuit zip-cord had been removed, so he couldn’t take it off himself, and a large black sheet covered the bedroom window, which was taped shut.
The room had no ventilation, the light switches were taped into the off position, all the wardrobe drawers and doors were screwed shut with handles removed, an electric heater had been taped so it could not be used, and the room was cold and damp.
Two CCTV cameras were aimed at the bed.
Lee, a retired mechanic, appeared small and frail but was in good spirits and unfazed by the commotion in the house.
He was taken to hospital and found to be dehydrated. There, he ate and drank well and gained substantial weight.
But his health deteriorated within a week, and he died on July 9 from pneumonia, in the context of frailty and dementia.
David Lee and the other person were charged with failing to provide the necessities of life and with keeping a vulnerable adult in unhealthy conditions.
He was also charged with assault, forgery and theft by a person in a special relationship, amounting to $216,000.
A forensic pathologist who conducted the autopsy told the coroner that Lee had been hospitalised on June 3 with pneumonia and discharged on June 12 with a prescription for antibiotics, which were only picked up five days later by David Lee, causing his father to receive only two days’ worth of a seven-day course of medication.
In sentencing the pair after a judge-alone trial in 2022, Judge Mark Callaghan found the failure to provide the antibiotics after a 10-day hospital stay was an aggravating factor, which increased the risk of persistent or worsening infection.
Health NZ investigates
Health NZ launched an independent review into Lee’s support and care, which highlighted systematic issues and gaps, according to the findings.
It was established that support services were alerted to welfare concerns regarding Lee in May 2018.
A nurse observed his unkempt and confused appearance but there was no follow-up visit.
Concerns were again raised in March 2019 with a social worker who found no evidence of neglect following a home visit.
That same month, a colleague of the social worker raised concerns with HealthCare NZ about Lee’s care. The manager reported no concerns.
A nurse on a home visit asked Lee how living with his son was, and was told it was “terrible and awful”.
Additional support was extended and the social worker returned to the case in June 2020 after a personal absence.
The social worker then learned of the cameras trained on Lee as David Lee showed them videos of his father’s insanitary and distressing toileting conditions.
David Lee said he used the wetsuit to manage the problem of incontinence, and the social worker told him it was “unusual” and that it would be discussed with a psychiatrist.
The social worker also learned of the inoperable bedroom heater, the blocked windows, and the room kept dark.
The inquiry heard that David Lee gave “explanations as to why each of these measures assisted with Norman’s care and wellbeing”.
The social worker documented the information, but it was not entered into the system until months later.
On the same day, the social worker raised concerns with a psychiatrist and was told to step back from the case.
An interdisciplinary meeting found the social worker had lost critical independence of the case and was advocating for Lee to stay in his son’s care.
The meeting concluded that the reported elements in the home didn’t sound appropriate.
Health NZ referred the social worker to the Social Workers Registration Board with serious concerns.
A confidential process was held and the social worker’s employment with Health NZ ended in late 2021.
The review concluded there was inadequate recognition, management and communication of clinical risk amid increasing evidence that David Lee was restricting his father’s movements, and that the increased risk wasn’t identified.
“There was, until June 2020, minimal information compiled about the state of the home.”
The Health and Disability Commissioner’s investigation
Meanwhile, the Health and Disability Commissioner also undertook an investigation and released its findings to the coroner in December last year.
That investigation provided a different picture.
It said Health NZ frameworks and processes weren’t functioning well, detrimentally affecting the support extended to the social worker and consequently impairing Lee’s care.
However, the social worker had a duty of care and Health NZ was entitled to expect adherence to policy frameworks, it found.
When reporting Lee’s concerning circumstances in June 2020, the social worker acted promptly and advised the right people, but made a “serious error of misjudgment” by telling his son of a planned uplift and jeopardising the plan to remove him to safety.
The commissioner was also critical of the “failure of the daily carers entering the home to escalate concerns for Norman’s condition”.
It was found that the use of a wetsuit for continence management “should have raised a red flag”, as should have the lock on the outside of his bedroom door, and this restraint also constituted a fire safety risk.
The commissioner didn’t accept HealthCare NZ’s view that four home carers couldn’t have been expected to escalate concerns unless they had the full picture, and that no single carer did.
It found that even without the wider context, the support workers should have identified individual signs of abuse, restraint and neglect and should have been trained to do so.
It noted the critical importance of support workers recognising signs of possible neglect, which was evidenced by circumstances in the case.
The commissioner commended Health NZ for promptly implementing recommended changes to its service provisions, frameworks and processes and commended HealthCare NZ for implementing changes, including creating a dedicated care and protection team.
Health NZ apologies
A Health NZ spokesperson told NZME it “extends deepest apologies to the family for their loss and recognise the profound impact of his death in 2020″.
“Health NZ acknowledges the coroner’s report and the findings made by the Health and Disability Commissioner.
“In line with our commitment to providing safe, high-quality care, all recommendations have been addressed and implemented.”
Coroner Borrowdale was satisfied, based on all of the information available, that there were no circumstances relating to the death that made an inquiry necessary.
She had made an extensive review of the evidence, specifically of the criminal prosecutions and other investigation outcomes, she said.
The coroner extended her condolences to those who loved, cared for, and mourned Lee’s death.
