Poor wound management led to an aged care resident having maggots found in her heel and the aged care home tried to cover it up, the royal commission has heard.
Annunziata Santoro lived in residential aged care at Assisi Aged Care Centre in suburban Melbourne.
Santoro moved into aged care aged 93 with dementia, type 2 diabetes, arthritis and arrhythmia and failing eyesight, but still mobile, in June 2017.
By May 2018 she had lost five-and-a-half kilos, 10 per cent of her body weight. The commission alleged that her weight was not monitored properly or on a regular basis, and said that Santoro’s family were not informed.
The commission heard Santoro sustained numerous injuries as a result of falls during her time at Assisi: one of which resulted in hip surgery, unremoved staples and a subsequent infected wound.
Santoro then developed a pressure injury on her right heel which, according to counsel assisting Peter Rozen, went untreated.
The wound deteriorated, and progression reports were not taken until two-and-a-half months later when a wound specialist was consulted.
By September 2018 Rozen said the wound was described by a care worker as “open to 50 cent size, is stage 3, and black in colour” and by October notes suggest “significant depth with likely bony involvement”.
He added that an independent nurse practitioner would later note that they were “able to see and feel bone”.
“Even worse was to come,” remarked Rozen.
By 11 October 2018 “eight maggots were found” in Santoro’s heel wound.
The commission heard a GP attending was then asked not to disclose the discovery of the maggots to Santoro’s family.
Dr Eric Tay told the commission that the Assisi nurse manager was panicked at the discovery and scared of getting into trouble.
“So, [she] sat me down and said, ‘We found maggots in the wound. What do we do?’ I replied, ‘We have to tell [Santoro’s daughter] and her family.’ She was tense. She was anxious,” he said.
“[She said] she could get in trouble if this was disclosed. She said that they will get really mad. I said, ‘I don’t think that changes my mind.’ She was continuing to be anxious and concerned.”
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