The Health and Disability Commission has found a charitable organisation that supports people with disabilities in breach of several codes after a staff member physically restrained a man in their care.
In a decision released on Monday, the Deputy Health and Disability Commissioner report found the man's sleeves of his jersey were tied in a knot which would have caused psychological distress.
The man, aged in his thirties, has limited vision, epilepsy, and is non-verbal. He lives in a residential service and regularly attended an Enrich+ Trust (Enrich) day activity programme.
In 2022, a staff member from the residential service was contacted to collect the man from Enrich but when she arrived, she discovered a support worker had physically restrained the man by pulling the sleeves of his jersey up over his hands and tying knots in them.
The man is known to pinch, punch and kick others, including support workers. When he becomes physically aggressive staff were advised to keep their distance and guide him to a safe place to calm himself.
On July 25, 2022, Enrich staff described the man as "very agitated". He was pushing, grabbing, and pinching, hitting his head against the wall and leaning heavily on staff members.
An Enrich staff member guided him to another room to see whether he wanted to spend time in a lazy boy chair and called residential service to ask for him to be taken home.
"While trying out these different ways to calm him down [the man] was more agitated and was grabbing me throughout so I moved him away to [another room] to sit in a lazy boy chair," she said.
"I reached out for his long sleeve [T-shirt], pulled down the long sleeves and covered his hands by tying a knot at both ends. I did this not in a negative sense but in a more positive sense for the safety of himself, myself and anyone else."
She said she continued to try and calm him but he got up and attempted to hit himself and the wall, so she approached him to ensure he did not fall.
"In doing so, he grabbed, struck and scratched me. This is when I tied both of [the man's] sleeves to a knot [so] that I could provide the close physical support to him and at the same time [minimising] his ability to scratch me," the woman said.
The support worker said she gave the man the option to sit or lie on a sofa bed and he chose to lie face down.
"This is a very common position for [the man] to be in. He chooses to lie this way as it appears it is a comfort to him and in the sensory room he can also feel the vibrations of the bubble column when it is turned on," she said.
The woman left him in the room with another staff member and two clients while she attended to other clients.
A staff member from the residential service arrived to hear the man grunting.
She found him in the room lying on his stomach with his legs dangling off the sofa bed and his long-sleeve jersey ends tied in a knot and then tied around the nail. She said his left arm was stretched upwards hooked onto a nail and his right arm was stretched downwards hooked onto a nail. The jersey knot was tied around one singular nail on both ends.
However, police were not able to find evidence of a nail/screw. They concluded that no criminal offending was detected and decided to take no further action.
"He is a victim with no justice who cannot see or talk to give his own statement of the abuse he suffered," the residential care worker said.
She untied him and calmed him down.
Deputy Health and Disability Commissioner Rose 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."
Since the event, two Enrich staff members have faced disciplinary action.
Wall recommended the support workers and service lead write letters of apology to the man and his whānau.
Enrich said work is underway to ensure the actions required by the funder of their service, Whaikaha, are completed as soon as possible, including the engagement of external specialist assistance. Enrich’s Restraint Minimisation policy and the Abuse and Neglect policy have also been revised and updated and all support staff now have to undergo the Safety Interventions course.
Wall recommended Enrich report to HDC with an update on the completion of the actions required by Whaikaha, and use this case as a basis for developing education/training on restraint and incident reporting for staff.
