LINKS CORPORATE MEDICINE WEB SITE Disclaimer The many extracts on these pages are from copyright material. They are owned by the reference given or its owner. They are reproduced here for educational purposes and to stimulate public debate about the provision of health and aged care. I consider this to be "fair use" in the common interest. They should not be reproduced for commercial purposes. The material is selective and I have not included denials and explanations. I am not claiming that the allegations are true. The intention is to show the general thrust of corporate practices as well as the nature and extent of any allegations made. Any comments made are based on the belief that there is some substance at least to so many allegations. Links to Site Maps Central Initial USA Australian International Corporate Practices (to print) Path to this page Home Australia Markets & aging Nursing homes The Companies overview Health care Hospital Corporatisation   Entry to Privatisation   Privatisation Background   Australian states Pathology & Radiology Gen. Pract. Corporatisation Aged Care Story of corporatisation   Nonprofit dilemma Aging bonanza Banks Nursing homes Home Care Breadth health corporat. Retirement Villages Nursing Homes Government    1985 to 1998    Correspondence    1998 to 2001    2002 to 2005    2006 Accreditation Nurses    People farming Residents & Relatives The Companies Not for profit homes Nursing Hm Comp The Companies overview Listed Companies Milstern DCA    Audit problem Ramsay Hlth Care Aevum Retirement Care Aus. Bigger unlisted Comp. Moran Hlth Care Tricare Regis Grp Unlisted Comp. Vic. A Illawaong Saitta/Neviskia CIS Holdings Unlisted Comp. Vic. B Eildon McKenzie SRS & Marnotta Enhance Peel Street Muskjest Lasalto & Easyplan etc Ellis & Elfam Dampier Bay Hastings Regional Navatha & Locksley Unlisted Comp. Other Aegis Sauve/Craigcare Kennedy Thompson Alchera Park Trans Dominion/Farad Gonzales Bresant Tolega & Karoona Peninsula Introductory page This corporate web site addresses the issues of corporate health care within a broad framework. A web page describing this broad context should be considered as an introduction to each page on the web site. If you have not yet read it then CLICK HERE to open it in another tab or web page. Content of this page The government's nursing home policies imploded with the Riverside nursing home scandal. Examination of this scandal gives a fascinating insight into the market, into Australian regulations, into government processes and into the way ideology, social processes and the people involved in them inexorably progressed what happened into a tragedy for all parties.  Australian section    Illawong Retirement Equity Pty Ltd The Riverside Scandal

Mar 2000 Summing it up

"In the long run, this will probably do some good for the industry as a whole.

"Riverside has definitely been the scapegoat. Before this, no one ever paid any attention to the plight of elderly people."
Evacuees face hospital trek Sunday Herald Sun March 12, 2000 (comment by residents family)

CONTENTS

• Overview
  • A Business
  • Regulation
  • Politics
  • The situation
  • The divide
  • The Story
  • Insights
  • Failure
•  Who are they?
  • Rabinowitz
  • Martyniuk and other owners
  • Dysfunction and bankruptcy
  • The early years
  • That meaningless clause in regulations
  • Internal disputes
  • Profitability
  • Other business interests
•  Past failures in care
  • Stories come out of the woodwork
•  The first surprise visit in Australia
• The kerosene bath scandal
  • Investigation into deaths
  • Riverside unable to cope with crisis
• Regulatory Failure
• Shifting the blame
• Why is the agency understaffed?
• The industry gets on board
• Closing Riverside
  • Residents moved into Ripplebrook
  • Authoritative opinion
•  Legal actions
• So much for economic ideology
• Bishop justified - well maybe?
• Summing up what happened
• Consequences for the whistle blowers
• Consequences for other staff
• Consequences for couples

A Business:- The Riverside scandal originated in a nursing home run by businessmen. The reports suggest that at least one had a personality which rendered him a risk. The focus was on profitability and they had no insight into the relationship between costs and care.

That they were there at all was a consequence of a shift in community perceptions in the Australian establishment. This saw commercial enterprises gain in credibility and influence. The commercial paradigm was seen to be viable in all contexts. It became legitimate, even desirable to provide care for vulnerable citizens through a mechanism whose primary aim was to profit from their misfortune. This was in direct conflict with the ethos and the understandings of the majority of those with experience, and actually working in the area. It was sold to the public by calling it reform.

Regulation:- The regulatory system introduced in 1997 was misconceived, under-funded and legally vulnerable. It was a product of an ideological belief in market systems and a political imperative to apply them. It was designed to please the ideological constituents, mainly the businessmen providing care. They contributed to its design.

The accreditation system was intended to be an industry improvement tool for motivated providers and not coercive or a deterrent. Staff visited to remediate. Surprise visits and Sanctions were a last resort.

This was largely impractical because of the number of homes, the pressures to dysfunction and the costs. The agency developed a complex documentary structure and rigid system for measuring standards which was out of touch with the real world of care and so became an imposition.

Politicians had learned nothing from the US experience but could not claim ignorance. During the previous 7 to 10 years I had personally circulated vast numbers of reports to them. These described the problems in the US market system and the failure of similar regulatory structures. Instead they were heavily influenced by trusted industry supporters like Andrew Turner and Doug Moran whom they considered to be credible authorities. None understood the critical difference between a system designed to help vulnerable citizens and one for making investors wealthy.

Those involved disregarded or did not understanding the reasons for failure of similar systems over many years. They had discounted the strong pressures to dysfunction which develop in health and aged care markets.

Oversight was designed to help the businesses on the assumption that they would be strongly motivated to comply with standards. The homes were given ample opportunity to prepare for infrequent visits. The system was set up to fail and it has failed. Riverside is a good example.

The accreditation agency was closely aligned with the political process. It was dealing with an unpredictable and irascible minister who blamed everyone but herself. It is likely that morale was low and that the agency had difficulty in employing and keeping adequately trained staff.

Politics:- The political system was one driven by ideology and political ambition. Minister’s political futures were determined by successfully implementing ideological prescriptions in their portfolios. At this time the all too flawed minister involved had leadership ambitions. She had been aggressive in her criticism of others but as Riverside showed she was readily panicked into precipitate action when her credibility and future came under pressure.

She had no experience of aged care and was very probably influenced by the disturbing Andrew Turner whose US company Sun Healthcare had been welcomed into Australia to provide step down and nursing home care. Turner, an eccentric market advocate had popularised the misconception that you did not need nursing skills to care for the elderly - a point of view welcomed by politicians in the USA. Many thousands suffered needlessly and died of neglect as a result. As in the USA the real costs of providing adequate care to the elderly were grossly under estimated.

The situation:- The minister and her government had promised much and all parties outside government were aware that she had not done what she had promised. It was not working and there were many problems. Riverside exposed the problems in a unique way and this received extensive press coverage and intense criticism.

The divide:- I have written elsewhere about the wide divide between the perceptions of businessmen and economists on the one hand, and nurses and patients on the other. In Riverside we see multiple divides; the businessmen, the politicians, the regulators, the nurses, the patients and relatives, and medical and lay experts. Few of them seem able to enter into the world of the other and as a consequence ineptitude and stupidity work their sad magic to everyone’s cost.

The Story:- The nursing home had been a recurrent problem for about 12 years and nothing effective had been done about it. When nurses complained about injuries to residents from the inept treatment of scabies the department delayed and then set up a consultative practice.

Press publicity precipitated the minister into ordering a long delayed and promised surprise visit. When the kerosene baths were disclosed this became a major national scandal. In the fallout the minister panicked and closed the home precipitously and without any consideration of the consequences for all involved. The entire process was mismanaged. The minister career was truncated, nurses lost their jobs, the community lost their resources, caring families were distanced or separated from their spouses and parents, and many ended in homes which were no better than Riverside.

I have arranged the material on this web page under issues rather than chronologically. The background story is summarised above and should be kept in mind to prevent confusion.

Insights:- The Riverside scandal more than any other example provides an insight into the failure of our systems. If we can get beyond our tendency to blame and point fingers, and accept our human fallibility then we might come to grips with the multiple system failures which lie at the root of some of the problems not only in aged care but in politics and in our society.

Behind Riverside lies our inability to confront the limitations in the one size fits all beliefs around which we construct our social systems. As a consequence we repeatedly attempt to patch the leaky bucket so that we don’t have to design another based on different principles. Riverside is no exception.

Failure:- The new market based system was less than three years old and clearly was not working. There were serious problems in many homes and the system which was designed to support the business community rather than protect the residents was not putting these unsuitable people out of business. The scandal at Riverside in 2000 was a good example and it became the catalyst used to blow open the failure of the government's controversial aged care agenda.

A major lesson from Riverside and multiple other failed homes is the importance of suitable people, people wanting to serve the community, part of that community and trusted by it, and not driven by the desire to make themselves rich. These are not the sort of people who enter a competitive marketplace or succeed there. They will take their drive and motivation to an area where they can realise their social selves in an area where their dedication is recognised.

The story of the events is long and complex but the insights gained are worth the effort.

The story of Riverside goes back several years and involves not only poor care but bankruptcy. Who were these people and what was their background?

It turns out they were businessmen, one already highly suspect, and two accountants. This seems to be another example of totally unsuitable people entering the sector from the business community. The issue of aberrant individuals in aged care is explored at greater length in relation to the companies Saitta Pty Ltd and Neviskia Pty Ltd and Primelife.

The reports suggest that one director, Vladymir Martyniuk, was removed from this position when the company came out of liquidation in 1999 but his ownership was not terminated. That this did not curtail his influence became apparent later. He held the purse strings. The reports suggest that his partner, Howard Rabinowitz, who claimed to be a prominent businessman continued to run the nursing home. Within months things were as bad as before.

We should not be surprised at this. When the home was closed in March 2000, Vladymir Martyniuk emerged to attack the decision and once again presented himself as a director. It was then revealed that management was paralysed by disputes between the directors and Rabinowitz on the one hand and two thirds owner Martyniuk on the other. Not surprisingly the regulatory device of barring a director, effective in a not for profit context, did not reflect the realities of ownership power in the marketplace. Ownership was hidden in a tangle of companies.

Rabinowitz:- Rabinowitz was a well known businessman with a finger in many pies. The reports suggest that he was prepared to spend money on the home. He was a millionaire. He did not have the courage to meet and speak with residents and their families.

Jul 1997 Other companies

A duly convened meeting of directors of Bintang Limited held on 9 July 1997, Mr Howard Rabinowitz resignation as a director was accepted by the Board effective 2 July 1997.
ASX-Bintang Limited (BIN.AX) Resignation of Director. Australian Stock Exchange Company Announcements July 31, 1997

Nov 1999 Another venture

FLEDGLING developer New Millennium Properties is set to give a strata title to the historic Century Building - an art-deco office tower directly opposite Melbourne Town Hall.
-------------------------
The project is being steered by Lightning Jack's main unit-holder, Capital Funding Equity.

Its chief financial backers are New Millennium directors Howard Rabinowitz, Michael Kinnon and Langer Avery.
Lightning sale of the Century. The Australian November 19, 1999

Mar 2000 Rabinowitz managing Riverside

THE scandal at Melbourne's Riverside Nursing Home had been "agonising" for one of its major backers, Howard Rabinowitz, a millionaire property developer who has also taken over the Lightning Jack Film Trust once associated with Paul Hogan.
--------------------
Mr Rabinowitz, 65, took control of the management of Riverside last year after rescuing it from liquidation.
Scandal `agony' of home's owner. The Australian March 3, 2000

Mar 2000 Rabinowitz would not meet angry relatives

Relatives of residents, disgusted at management's refusal to attend a meeting with them on Thursday night, said one of the options canvassed by a company representative was the building of a new nursing home nearby.

The granddaughter of a resident said she had been told the operators considered it too expensive to make the existing home comply with new accreditation standards.

The nurse who spoke to The Australian yesterday said the home's owner, Howard Rabinowitz, had been at the nursing home on Thursday night but he did not meet with relatives.
Nurses were shocked by kero burns. The Australian March 4, 2000

Martyniuk and other owners:- Actual ownership was initially far from clear. Two accountants were the front men. Then Rabinowitz put up his hand. Later still it became clear that Martyniuk owned two thirds of the company and that there was a third owner.

Feb 2000 Accountants put up their hands

Riverside Nursing Care Pty Ltd is owned by a pair of accountants and investors: Paul Grinwald, of Leaburn Avenue, Caulfield North, and John Wilson Irving, of Valley Road, Skye. A receptionist at Mr Grinwald's office said he was on holidays overseas.

The two men are listed in Securities Commission documents as directors of Illawong Retirement Equity Pty Ltd, which took over the company in January last year after it had been in the hands of a liquidator for nine months.
Monitors Blew Whistle On Home 10 Months Ago The Age February 26, 2000

Feb 2000 Rabinowitz the proprietor

He (John Irving) revealed that Caulfield North businessman Howard Rabinowitz was the registered proprietor of the nursing home with the Federal Health Department.

He defended Mr Rabinowitz, saying he did not believe he should be held responsible for the alleged abuses of residents.
Bishop dismisses demands for funds. The Australian February 28, 2000

Apr 2000 More information on owners

Department documents from 1993 list the proprietor of the home as Riverside Nursing Care Pty Ltd and the company's then directors as Mr Vladymir Martyniuk, Mr Bruce Walker and Mr Cecil King.

When residents were moved from Riverside last month, the home was still being run by this company, but its management had changed significantly.

Australian Securities and Investments Commission records show that when patients were moved, the directors were Mr Paul Grinwald and Mr John Irving, nominees of the property developer, Mr Howard Rabinowitz. In a network of interlocking companies and trusts, Mr Rabinowitz appears to own one-third of the company and Mr Martyniuk up to two-thirds.

Mr King said yesterday he had disposed of his interest in the home in 1997.
Nursing Home Under Scrutiny In '93 The Age April 6, 2000

Dysfunction and bankruptcy:- The story behind the company was disturbing and included a dysfunctional director and a bankruptcy. One of the interesting titbits to emerge was that the company at one time owed the department a lot of money.

Feb 2000 A sequence of mismanagement

But a check of the home's history would have found a sequence of mismanagement going back years.
------------------
That liquidator was the Carlton-based insolvency accountant Mr Greg Andrews. He said he had dealt with insolvency in a number of nursing homes. In this one, he said, conditions were bad.

``I am not saying it was the worst I have seen. Others were worse,'' he said. ``But as far as government regulations were concerned, it was a total failure across the board. Just as disturbing from a liquidator's point of view was that it owed the federal Department of Health $810,000.''

He said this was an extraordinary debt for a nursing home.

Mr Andrews' report on management of the home said the previous company management, under the direction of Mr Vladimir Martyniuk, had been the reason for the debt.
Monitors Blew Whistle On Home 10 Months Ago The Age February 26, 2000

Feb 2000 Martiniuk barred from being a director

THE manager of the Riverside Nursing Home was considered so inept that a liquidator appointed to solve the company's mounting debt problems insisted he be banned from managing the business for at least 12 months.

Vladymir Martiniuk, also a part-owner of the business, was removed from his position in 1998 after liquidators called in by Riverside creditors discovered the company owed more than $1.5 million.
----------------------
Mr Andrews said while Mr Martiniuk and co-owner Howard Rabinowitz had extinguished the debt by 1999, he had felt compelled to impose conditions on the deed of company operations, which allowed Riverside to continue operating.

"Obviously there was some disquiet with Mr Martiniuk's performance," Mr Andrews said yesterday. "Really we were seeking undertakings for everybody's benefit that he would not be returned to the management of this nursing home for 12 months.

"There was also an undertaking to spend $80,000 on upgrading the facility and that was accepted by everybody."
------------------------
A medical source, who had dealt with Riverside Nursing Home, said Mr Rabinowitz had a reputation in the industry as being difficult, particularly where there had been concerns about the standards at Riverside.
Liquidator demanded ban on Riverside mis-manager The Australian February 28, 2000

Mar 2000 Government recovered money in 1998

Senator Evans (opposition shadow minister) also alleged that the commonwealth had cut care subsidies by $800,000 to Riverside and asked in the Senate whether this had forced the home to cut staff and reduce the quality of care to residents.

Government sources confirmed the federal Government did complete an action to recover unaccounted-for care subsidies from the home in 1998.
Spot check neglected after resident's death The Australian March 17, 2000

The early years:- The story went back to 1993 and the department had wanted to remove Martiniuk at that time. They did not have the power to do so.

Mar 2000 Problems started in 1993

On Christmas Eve 1993, officials noted that the ``proprietor did not appear to recognise problems and could not believe they warranted sanctions''.
History Of Problems At Home The Age March 3, 2000

Apr 2000 Government backed away from removing Martiniuk in 1994

Federal authorities considered removing the proprietor of the Riverside nursing home six years ago, after a series of complaints.

In early 1994, senior officers of the federal Department of Health grappled with the legal implications of removing the proprietor, as well as the impact on elderly residents, according to documents obtained by The Age.
--------------------------
The documents obtained by The Age reveal that in January 1994 a senior departmental official wanted the department to consider revoking the ``approved operator/officer status'' of the home's proprietor. However the department was given legal advice that such action could lead to the home's closure, an outcome officials wanted to avoid.

``We are faced with the prospect of closing the home and relocating 60 residents if the proprietor does not budge. This is clearly not feasible in an environment where there is 98 percent occupancy throughout the state. Alternatively, we could back down on our principles and be made to look ridiculous,'' one officer wrote.
Nursing Home Under Scrutiny In '93 The Age April 6, 2000

That meaningless clause in regulations

The inadequacy of government regulations prohibiting undesirable people from being directors were revealed after the home was closed. Although we were told that Martyniuk was no longer a director he presents himself as such and speaks for the company in March 2000. He is still the majority owner.

Mar 2000 Martiniuk presents himself as a director and speaks

Nursing home director Vladymir Martyniuk yesterday said there had been "a lot of rubbish" talked about his now-defunct nursing home.

"I have spoken to some of the relatives and some of the staff," Mr Martyniuk said. "They are happy and want to stay."

The home is owned by Riverside Nursing Care Pty Ltd, which is in turn owned by Mr Martyniuk, 54, Cecil Raymond King, 76, and Illawong Retirement Living - a company owned by wealthy businessman Howard Rabinowitz, 65, who is also a partner in New Millennium Properties and the Lightning Jack Film Trust, formerly associated with Paul Hogan.

Chris Cooper, who owns the building from which Riverside operates, put a written proposal to the Federal Government a week ago to take over management, but has not had a reply.
Desperate bid to keep home open. Herald-Sun March 7, 2000

Internal disputes:- Some of those involved eventually spoke out about the internal disputes which had paralysed management. As always in the marketplace these were about money and not care.

Although he was prevented from being manager or director Martyniuk still owned two thirds of the company, in essence giving him control. Effective management was paralysed by disputes between director and manager Rabinowitz, and majority owner Martyniuk. A third past owner was named.

Mar 2000 Debarred Martiniuk exerted control through majority holding

The dispute between Mr Vladimir Martyniuk, the majority owner of the company that has run the home at Patterson Lakes since 1985, and his partner, Mr Howard Rabinowitz, caused an impasse in the management of Riverside Nursing Home Pty Ltd.

The partners' former business associates said the dispute was over who controlled the company, which since early last year has been run by two agents of Mr Rabinowitz, accountants Mr Paul Grinwald and Mr John Irving.

The revelation of Mr Martyniuk's continued behind-the-scenes involvement raises questions about the reforms to the nursing home industry trumpeted by the federal Aged Care Minister, Mrs Bronwyn Bishop.
---------------------------------
Mr Martyniuk made a bid to gain control over two-thirds of the shares of the managing trust in January 1998. But Mr Rabinowitz, who owns the remaining third, ousted him as manager after the company was placed in receivership in May that year.

The insolvency accountant who took over as administrator, Mr Greg Andrews, said at the time the home failed to meet the Government's standards across the board.

Mr Martyniuk had been company secretary and manager since 1985 but, under the liquidator, the home was found to owe $850,000 to the federal Health Department.

In the liquidator's report, Mr Martyniuk was blamed for management failings, and in the restructure it was stated he was to have no say in running the home.

But he still owns up to two-thirds of the shares through a network of interlocking companies and trusts.
Dispute Lies Behind Riverside Closure The Age March 9, 2000

Mar 2000 Owners were unwilling to put in money

THE owners of Melbourne's Riverside Nursing Home had failed to put in the money needed to bring the home up to the standards recommended by its business managers, a director of its trustee company claimed yesterday.

Paul Grinwald, a non-financial director of Riverside, told The Weekend Australian all the three owners now wanted was to get their licence back so they could sell up and move on.
----------------------
Since 1998, part-owners Vladymir Martyniuk, 54 and Mr Rabinowitz, 65, have been in dispute with each other after Mr Martyniuk was told by the Health Department to relinquish day-to-day management of the home when officials found serious problems with its administration.

A series of business managers was employed by Mr Rabinowitz to run the home but, according to Mr Grinwald, most of their attempts to bring it up to acceptable standards were thwarted by the partners' refusal to spend money. "A lot of money was needed to improve that place - Mr Rabinowitz was willing to put in his third of the cost but the other two partners refused," he said.

The third unit trust member, Cecil King, still held a non-managerial role in the company but, according to Mr Grinwald, he was "desperate to get out".
Owners `ignored' Riverside's needs. The Australian March 11, 2000

Profitability:- An interesting revelation came in March 2000. This home which had been under-funded, understaffed and in appalling condition was actually profitable making $200,000 a year.

Mar 2000 Riverside was profitable

Riverside's administrator, David Lofthouse, estimated the Patterson Lakes home was running at a half-yearly $100,000 profit.

He said the forced closure of the home had left trade debts of about $70,000 and outstanding employee entitlements of up to $300,000.
---------------------
Mr Lofthouse had no comment on whether Riverside was in a position to return a "healthy" profit to its owners, Vladymir Martyniuk, 54, Howard Rabinowitz, 65, and Cecil King, 76, who has no management function.
Probe on death. Herald-Sun March 9, 2000

Other business interests:- The same owner or owners also had an interest in other aged care facilities

Feb 2000 Rabinowitz owned other homes

Mr Rabinowitz is also believed to have an ownership stake in two other Victorian retirement homes, Brighton Lodge in the affluent bayside Melbourne suburb of Brighton, and Queenscliff Nursing Home on the Bellarine Peninsula.

Both homes are believed to have been the subject of a weekend investigation by the Aged Care Standards and Accreditation Agency. They were cleared of any serious problems. - SECT-Local.
Liquidator demanded ban on Riverside mis-manager The Australian February 28, 2000

Mar 2000 Agency looked at them

A spokeswoman for Aged Care Minister, Bronwyn Bishop, told The Canberra Times that when the issue of Riverside came to light, the agency turned its attention to the two other nursing homes Mr Rabinowitz had an interest in which included Canberra Nursing Home, formerly Allambee.
Canberra Link To Melbourne Home Canberra Times March 8, 2000

The department and the agency could not have been unaware of this track record. Only 2 years before the company owed them $800,000 while it was in receivership. There was also a long history of serious problems in the home. Regulators had taken action.

March 2003 Recurrent problems and sanctions going back to 1988

Fears about safety at Melbourne's Riverside Nursing Home - the centre of a national scandal after the revelation last month that residents were bathed in kerosene - first emerged in 1988.

A recent report by the federal Department of Aged Care reveals the home, in Patterson Lakes, was several times rated to be in need of ``urgent action'' under the former Labor Government.

The report, obtained by The Age, said Riverside was identified as a ``home of concern'' on 29 March 1993 but it was not ``declared'' as such until 13 December 1993. It remained on this high alert until 3 September 1996 when it achieved a perfect score in a visit to monitor standards.
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But the report shows more than a decade of problems at Riverside under Labor ministers Mr Peter Staples, Mr Brian Howe and Dr Carmen Lawrence.

The report said the federal department first identified that standards for dignity were not met in 1988. It said urgent action was required in relation to issues of continence, infection control, health care and restraint in 1992 and there had been a ``deterioration in standards'' in 1993.

The home was placed under financial sanction for six months from 1993 to 1994, and again in 1995.
-----------------------
In January 1994, the department had a ``legal discussion'' about revoking the home's approved provider status.
History Of Problems At Home The Age March 3, 2000

Apr 2000 Review of 1993 findings

Inspectors who visited the home in October 1993 alleged it had ``offensive urine odors'' in the activity and day rooms, that residents could not be assured of receiving the correct medication and were at risk of inappropriate restraint.
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The October 1993 inspection recommended ``urgent action'' to improve residents' health care, freedom of movement, privacy and dignity. According to the inspection report the stench of the carpet in the day rooms and activities room discouraged visitors.
Nursing Home Under Scrutiny In '93 The Age April 6, 2000

Feb 2000 Review of 1998 findings

An earlier agency assessment conducted in the first half of 1998 found the home had failed all but three of 29 aged care and home maintenance standards. The report found skin irritations and rashes were widespread among the residents and were mostly left untreated. It also found that a male resident was passing blood in his urine but nothing was done about it for 11 days.
Bishop silent on delay over aged-care scandal Courier Mail February 26, 2000

Feb 2000 Review of 1999 findings

The same agency conducted further assessments on Riverside again in April and July 1999, with the July report giving the home an "unacceptable" rating. That report expressed concern about medication being given to residents and that some were left in constant pain because they had not been given their prescribed medication. Added to that was poor nutrition, a risk of dehydration and poor management of wounds such as pressure sores from being left lying in the same position all day. It reveals a pattern, well known to the authorities entrusted with monitoring the health and safety of our 3000 nursing homes.
Even Dickens would be appalled. Courier Mail February 26, 2000

Mar 2000 Urgent action advised in May 1999

A leaked review of the Riverside Nursing Home revealed yesterday that conditions there had been dire as far back as May last year. The Aged Care and Accreditation Standards Agency report recommended that "urgent action" be taken in almost all aspects of the residents' health, lifestyle and physical environments.
Bishop `failed to act'. The Australian March 2, 2000

Feb 2000 Nursing unions had a big file

It was a case of ``what is it this time'' when the call came to the Australian Nursing Federation offices on the morning of Monday 17 January and the name Riverside Nursing Home was uttered.

Over the years, a litany of problems has built a thick union file on the home.

Last year complaints to the Federal Government about the home included weevils in the residents' cereal, bedpans washed in a bucket by staff who were not given gloves, insufficient bandages, beds without brakes and wheelchairs that didn't wheel - to mention just a few.
A Call That Took A Month To Answer The Age February 26, 2000

Feb 2000 An inside source

An industry source said conditions inside the Riverside Nursing Home were disgraceful, with residents dehydrated, one patient with maggots in a wound, blood left on a shower curtain, torn lino, ripped fly-screens and leaking bed-pan flushers. The list of faults had filled two full pages, the source said.
Kersosene baths scandal puts heat on aged care. The Australian February 26, 2000

Mar 2000 Nurses have been complaining for years

The latest controversy is symptomatic of a raft of official complaints about the Riverside Home dating back to January last year. Weevils in the food, a lack of bed linen, inadequate supplies of latex gloves and lubricants all necessary to good care were among allegations raised by nurses against the home.
Golden Oldies Sydney Morning Herald March 2, 2000

Stories come out of the woodwork:- As the scandal broke relatives and nurses came forward to tell of their past experiences at Riverside. Several nurses had resigned in disgust. One nurse’s comment "I'll never go back to any nursing home again" expresses a fundamental problem in the provision of care for profit. Nurses who actual care are so turned off by their experience of "people farming", and their inability to do anything about it that they leave the profession. The best people leave. Dysfunctional individuals will tolerate what is happening fill the void and are promoted to senior positions.

Not only are staff shortages exacerbated but the service is dehumanised. Those who can do what their managers require and put up a mental barrier advance their careers and come to dominate.

Feb 2000 Several nurses had resigned

The sources said staff felt the health and safety of the residents was at serious risk as several residents had recently been admitted to hospital.

Sources said three nurses had resigned from the home in the past few years because of alleged intimidation by management over complaints about conditions.
Nursing home risks lives Herald-Sun February 18, 2000

Feb 2000 Daughter of a past resident

THE daughter of a Riverside Nursing home resident claimed she was barred from seeing her dying mother and was not told when she died.

Merle Noble said nursing home staff would not allow her to see her mother in the last four months of her life.

And she said yesterday she only found out her mother, Jean, died when she read the death notices.
----------------------------
"In the four months before she died I tried to see her about six times," Miss Noble said.

"There was always excuses made.

"Most of the time they said it was no good because she won't know me.

"Or they said she's gone out on an outing or she's not there.
Daughter's visits refused Herald-Sun February 26, 2000

Mar 2000 Why nurses abandon the profession

AN elderly resident at Melbourne's Riverside Nursing Home was denied oxygen after she choked on a pancake in an unsupervised room, a former employee said yesterday.

The Melbourne nurse who worked at Riverside last year says the experience was so traumatic she never wants to work in aged care again.

Adelaide Ericksen, a registered nurse who was assigned casual shifts at Riverside through a nursing agency, said the home was "old, damp and dirty" and nurses worked in a climate of fear.

"The nurses there were terrified," Ms Ericksen said yesterday. "The morale there was terrible."

Ms Ericksen worked just three shifts at the home and was so appalled by her experience that she refused to work there again.

She told The Australian she had been disturbed by the overcrowding of residents in one small day room and the sense of panic among patients that they might not receive their medication.

"Patients and relatives were just at me from all corners - they seemed so anxious that their medication was not going to be given," she said.

There was also a serious shortage of experienced nursing staff with only a few state enrolled nurses, who undergo one year's training, and the rest nurses' assistants with just six weeks' training.

But what most dismayed her was an incident where a patient almost choked to death after eating a pancake in an unsupervised room.

The woman, one of many residents unable to digest solid food, had taken the pancake during a cooking session with an untrained volunteer worker.

Ms Ericksen revived the woman after she was brought to her "blue and limp" by two junior nurses.

But she was then forbidden from administering oxygen to the patient - standard medical procedure following asphyxiation - by a senior nursing staff member.

"I had to hide the oxygen tank and wait five minutes around the corner until she'd gone and then I gave the oxygen to her (the patient)," she said.

"While I was waiting, one nurse came up to me and seemed absolutely terrified and asked me not to make her (the senior nurse) angry."

While Ms Ericksen subsequently submitted a written complaint detailing the fact that the patient had been denied oxygen, she was unaware if any action was taken.

"It was dreadful, disgusting," she said. "I felt sorry for the patients but I just won't go back. I'll never go back to any nursing home again."
Riverside choke case denied oxygen - nurse. The Australian March 1, 2000

Mar 2000 The sort of people who are promoted

Former nursing staff, who have asked to remain anonymous, have told the Herald Sun the behavior of the home's director of nursing and the sister in charge contributed to an atmosphere of fear and intimidation.

One registered nurse, who quit shortly after the bathing incident, said the mood was one of foreboding and said she warned other nurses to get out before it was too late.

"I believed something would happen there. I had no idea it would be so quick" she said.
Riverside appeal Herald-Sun March 11, 2000

Mar 2000 Skimping on basic equipment is very demoralising for staff

The nurse said that management ran the nursing home "on a thread" and staff had done the best they could.

"Riverside was run by the wrong people," she said. "There were 60 residents, yet if you asked for soap, you were given five bars.

"They skimped on the linen. There was not enough and it was so worn. They skimped on cleaning.
--------------------
"The staffing levels weren't adequate.

The nurse said the kerosene baths "were the worst things that could have happened".

"The girl who ordered them had been there only four to six weeks, and she told the director of nursing that a doctor had said the baths were OK," she said.
Evacuees face hospital trek Sunday Herald Sun March 12, 2000

May 2000 Understaffing further demoralises

The nursing director who decided to bathe elderly residents of a Melbourne nursing home in diluted kerosene says it was the worst decision she ever made and one she deeply regrets.

She told ABC's Four Corners program she may not have made the decision had she been less overworked, but also said staff, rather than the home's proprietor, had been made accountable for its problems.

"The morale of the nursing home was going down because everyone was overworked. They were stressed out, they couldn't look after the residents that they wanted to look after them," said Ms Taylor, who had been at the home 13 years.

She said in hindsight, she may not have made the decision to go ahead with the kerosene baths if she'd been less "emotionally tired and drained and overworked".
Riverside nursing director regrets kerosene baths decision. Australian Associated Press May 1, 2000

 

The agency had been dismissive of staff who complained about the kerosene baths even though Riverside was already known to have major problems. They did not seem to know what their powers were. They set out on a process of mediation.

While the agency had the power to make surprise visits they had never done so. Homes normally had plenty of time to prepare themselves for a one off accreditation and then go back to business as usual for another 3 years.

Adverse publicity precipitated the first surprise visit to Riverside. At first the kerosene bath incident was not known to the press - at least not in a way which could be published. They were pressing the minister about the failure to meet her 2 year old promise to conduct surprise visits.

What is interesting is the amount of information released publicly. All too often information, especially involving large groups does not appear for several months, and on other occasions legal grounds are found for a delay.

Feb 2000 First ever surprise visit precipitated by publicity

A NURSING home inspected seven months after it was rated "unacceptable" has been accused of placing resident's lives at risk.

The Melbourne home allegedly had poor fire safety, lax infection control and out of date medicines.

The inspection was ordered by Aged Care Minister Bronwyn Bishop this week after the Herald Sun revealed that not a single random inspection had been carried out by her department in two years.

The 60-bed Riverside Nursing Home at bayside Patterson Lakes was assessed by the Aged Care Standards and Accreditation Agency in April and July, uncovering many alleged breaches.

Management of the home had also failed to ensure correct medication was administered to inmates.

The Federal Opposition said yesterday staff at the home lodged a complaint with Mrs Bishop's department on January 17 citing concerns about the safety of the elderly residents. Sources told the Herald Sun that when one of them phoned the federal Department of Health and Aged Care an officer said: "Well, there's not really a lot we can do but we can approach the management."
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Opposition aged care spokesman Senator Chris Evans said the department had planned to use mediation to deal with the complaint, not a surprise visit.

"They knew there was a serious risk to health. They had known for seven months. The only thing that forced the Minister's hand was two days of bad publicity."

On Tuesday, the Herald Sun revealed that the agency, which is charged with monitoring health and safety at Australia's 3000 nursing homes, had not conducted a single surprise visit to a home in two years. This was despite more than 4000 complaints.

Mrs Bishop defended the agency saying surprise visits were a last resort. The department identified 29 nursing homes in the past year where residents were at serious risk.
Nursing home risks lives Herald-Sun February 18, 2000

Feb 2000 Some information released

The Riverside Nursing Home at bayside Patterson Lakes also faces allegations of poor fire safety, lax infection control and use of out-of-date medicines.
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Ms Bishop said the audit had also revealed concerns over the administration of drugs to residents and serious concerns about methods of treating skin conditions, including kerosene baths. It also involved poor management of incontinence and environmental and safety issues arising from inadequate building maintenance.
Care for aged - a kerosene dip The Australian February 25, 2000

Mar 2000 Report released within weeks

The Aged Care Standards and Accreditation Agency report said during an inspection on February 16 and 17, evidence of serious risk to the health, safety and well-being of residents was identified.

"Medication is not safely administered, hydration needs are not met and residents' skin integrity is at serious risk," the agency said in the report released today.

Treatments used by care staff on residents were often out of date and inappropriate and the oral care of residents was poor.

The comfort and dignity of terminally ill residents was also not maintained.

The agency said continence aids such as nappies and pads were used to manage incontinence rather than as a device to assist.

Staff confirmed that residents were left for extended periods of time in wet continence aids and two residents' relatives confirmed that when residents requested to go to the toilet, they were consistently told they had to wait until after lunch by some members of staff.

A chair used to transport residents to and from the toilet and the shower had a bare wire holding the seat onto the frame.

"This could easily tear resident's skin while in use to transport residents to and from the toilets and showers as residents sit directly on the toilet seat of the commode during transport," the agency said.

"Residents are at serious risk of skin tears on the genitalia or buttocks due to the bare wire holding a commode seat on to the frame."

The agency said interventions documented were largely inappropriate and there was excessive use of restraint.

"Residents living at the service are at serious risk, as they can not be assured of receiving appropriate clinical care," the report said.
Riverside Nursing Home a serial offender - report Australian Associated Press March 14, 2000

Mar 2000 More information

SCABIES was only one of the problems afflicting residents at the Riverside Nursing Home, it emerged yesterday. Previously unreleased reports from the agency which inspected the home show residents were at risk of food poisoning, maggots infesting wounds, severe dehydration and other problems from a lack of proper care.
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It (the agency) found:

A RESIDENT had maggots inside a sore and a note attached to the wound chart which said "No mention to family please".
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Residents were also at serious risk of:

FOOD poisoning because the home's freezer broke down and the cook had been asking for a new one since November.

SEVERE dehydration because of lack of staff to provide drinks.
Resident's wound `had maggots' Adelaide Advertiser March 15, 2000

A few days later the story of chemical burns broke. The home had elected to treat a scabies infection with kerosene baths, an old wives remedy from the beginning of the previous century. They failed to get a medical opinion to confirm the diagnosis and a prescription for more costly modern treatment. I trained more than 50 years ago in a country where scabies was very common. I have never heard of kerosene as a treatment!

Registered nurses had confirmed that the kerosene was harmful by phoning a poisons information centre. They refused to comply. Instead untrained staff were ordered to bath the residents the next day.

Seven nurses who found the blisters blew the whistle and lodged complaints with the department.

The department was not receptive. It sat on its hands for 4 weeks and then acted only after the minister was contacted by the press.

Mar 2000 Kerosene baths on 16 January 2000

WHEN staff at Riverside Nursing Home noticed four residents had scabies in December, they sought advice from the Health Department.

But the advice to use lotion to treat the condition went unheeded, leading to kerosene baths a month later.

On the weekend of January 15 and 16, the director of nursing and a weekend supervisor, also a registered nurse, allegedly decided to bathe the 60 residents in kerosene.

According to two previously unreleased reports from the inspection of Riverside by the Aged Care Standards and Accreditation Agency, neither nurse sought permission from residents' relatives.
Staff given lotion advice Herald-Sun March 15, 2000

Feb 2000 Delay of 4 weeks after complaint

It has been learnt that up to seven staff complained to the department on January 17 but it was nearly four weeks before federal officials visited the home.
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The registered nurse interviewed by The Advertiser said staff had been ordered to use the kerosene by a nursing supervisor.

The nurse, who did not want to be identified for fear of being sacked, said nurses rostered on at the home on the weekend of January 15 and 16 refused to carry out the instructions.
----------------------------------
A spokeswoman for the Australian Nursing Federation's Victorian branch said it was clear the Government's reforms were not working when complaints like this were not acted upon for weeks.
BATHED IN KEROSENE. Adelaide Advertiser February 25, 2000

Feb Staff refused to use kerosene

As a precaution, they made two phone calls. One went to the accident and emergency department of the Frankston Hospital. The other went to a drugs and poison information line. Their concern was confirmed: kerosene baths were inappropriate under any circumstances.

The night staff refused the order to give the baths.

But the next morning, other staff were given the order and - whether through ignorance about the inappropriateness of the procedure or through fear of the consequences if they refused - they complied.
A Call That Took A Month To Answer The Age February 26, 2000

Feb 2000 Attempts to alter records - nurses behave responsibly

They were towel-dried but not rinsed with fresh water before being returned to their beds with the same linen, the nurse said.

The nurse said a number of the residents later complained of feeling sick and by the next day seven had come out in severe blisters.

"You should have seen the blisters ... it was disgusting, it was cruel," the nurse said.

"The Health Department knew about it on the 17th of January but did nothing."
-----------------------
The nurse alleged attempts were made to alter records that indicated injuries were caused by the kerosene baths and had told staff not to tell anyone of the baths.

Nurses arriving for the day shift at the home on Monday, January 17, called in a doctor when blisters were discovered on patients and about seven made complaints to the Department of Health and Aged Care.
BATHED IN KEROSENE. Herald-Sun February 25, 2000

Mar 2000 Hiding what happened

The agency found there had been an attempt by some staff to change residents' case notes to hide evidence of the baths.
Staff given lotion advice Herald-Sun March 15, 2000

Mar 2000 The chemical burns

The nurse said she and other staff members were "beside themselves" as they treated seven residents for burns and blisters after 57 people were bathed in a kerosene solution on January 15 in an attempt to treat a scabies outbreak.
Kero bath for dying woman. The Australian March 4, 2000

Mar 2000 Conditions in the home

TWO damning reports surfaced yesterday which reveal the full horror of conditions at Melbourne's Riverside Nursing Home and prompted claims that Aged Care Minister Bronwyn Bishop was negligent and should have acted earlier to close down the home.

The two reports, carried out on February 17 by the Government's aged care watchdog, allege a resident died after a kerosene bath and patients were at risk of developing maggot-infested pressure sores. These are virtually the same allegations contained in a February 29 report relied on by Mrs Bishop to announce the provider's licence had been revoked.
-----------------------------------
It reveals more than 90 failings in personal care and arrangements for the residents.
---------------------------------
Twenty-two residents with catheters and feeding tubes entering their bodies through open wounds were at risk of internal poisoning.

It says there was an ongoing serious risk that residents' open wounds could "become flyblown and infested with maggots" and that nursing staff were instructed not to tell relatives about the infestations.
Risk of flyblown open wounds at Riverside. The Australian March 15, 2000

Mar 2000 Thirteen residents burnt

The Aged Care Standards and Accreditation Agency reported that 13 residents not seven as originally reported received blisters and burns from kerosene baths given to treat scabies.

The agency reported that the residents at the home were at "serious risk".
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A WOMAN was vomiting blood before she was bathed in kerosene on January 16 and died seven days later on January 23.

ONE resident returned from hospital on January 14 and was noted to be unwell both before and after the kerosene bath.

SEVENTEEN residents had open wounds, two had tubes into their stomachs, two had catheters and one had a colostomy.
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All 60 of the home's residents were bathed for up to 10 minutes each in a bath containing 30 millilitres of kerosene. "A dying resident was bathed in kerosene, a process that must have been extremely distressing and frightening," the agency's first inspection report said.
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Within 24 hours of the baths, it became apparent according to nursing staff notes that 13 residents had various skin problems.

They included "blisters, severe rash, measle-like rash, large raw areas ... blisters that burst, pus-filled blisters, rash all over body".
Resident's wound `had maggots' Adelaide Advertiser March 15, 2000

Mar 2000 It gets worse

Conditions at Melbourne's Riverside Nursing Home were far worse than previously thought, with new revelations that even residents with intravenous tubes were bathed in kerosene.

The Federal Government's Aged Care Standards and Accreditation Agency report, parts of which were released yesterday, says that when residents were given baths with 30 millilitres of ``poisonous'' kerosene in them, fumes were so strong that the bathroom door was left open, fans were positioned to blow the smell away and staff were advised to take ``constant breaks''.

``The baths were not effectively cleaned or decontaminated between each resident. Some residents had open wounds, catheters and feeding tubes into their abdomens, and one a colostomy,'' it added.

Those residents ``were likely to have had the toxic kerosene solution tracking down into their bodies''.
Riverside Revelations Worsen Sydney Morning Herald March 15, 2000

Mar 2000 Residents scarred

Many of the elderly residents carry scars from the episode with seven suffering second-degree burns, severe blistering and bleeding.
State govt ready to help evacuation of elderly - minister Australian Associated Press March 5, 2000

Feb 2000 Dickensian care

"This is the sort of treatment that went out with Dickens, rather than something we would use in the 21st century," Dr Brand (President Australian Medical Association) told AAP.
Vic - Angry reatives visit loved ones at kerosene nursing home. Australian Associated Press February 25, 2000

Feb 2000 A cost cutting exercise ?

- - - - - which a number of the relatives hinted was the result of cost saving to avoid having to pay for ointments at less than $20 a bottle.
Angry Families Ask: How Could This Happen? The Age February 26, 2000

Feb 2000 A cheap alternative

Another medical practitioner yesterday speculated the kerosene could have been a crude attempt to save money by choosing the cheap alternative of a can of kero from the local petrol station rather than $10 bottles of lotion for the 57 elderly people.
Even Dickens would be appalled. Courier Mail February 26, 2000

Mar 2000 Interpersonal dynamics

The director of nursing at Riverside, Allyson Taylor, who agreed to the kerosene baths after a phone call from the supervising nurse, has since resigned and is believed to be suffering from a stress-related illness.

The supervising nurse who suggested the kerosene baths has also left but is working at other hospitals in the area.

The supervising nurse "was not at all liked or respected by the other nursing staff, who fought against the kerosene baths", the registered nurse said.
Nurses were shocked by kero burns. The Australian March 4, 2000

Investigation into deaths

One of those bathed was a patient near death having palliative care. The way in which the minister and her department handled her death is simply one of the many examples of the minister’s insensitivity and ineptitude. From there it escalated as investigations were commenced into more and more deaths. The ineptitude and insensitivity defy belief. In the end there was no outcome from any of this.

Mar 2000 A death

One week after the kerosene bath, one woman, who was receiving palliative care, died from a haemorrhage.
Kero bath for dying woman. The Australian March 4, 2000

Mar 2000 Police to investigate

Mrs Bishop told parliament she had been concerned enough to ask police to investigate the death.
Report referred to AFP for further investigation Australian Associated Press March 8, 2000

Mar 2000 An expected death

It is understood the woman, who died a few days after being bathed in diluted kerosene, was receiving palliative care.
Probe on death. Herald-Sun March 9, 2000

Mar 2000 Was it kerosene too?

Mrs Cucuzzella had been fitted with an open feeding tube to her stomach and some of the nurses now fear kerosene may have entered the tube.
Riverside appeal Herald-Sun March 11, 2000

Mar 2000 Insensitivity or ineptitude

Josephine said her anger was compounded when she discovered through the media that the resident whose death was to be investigated was her mother.

"I think it would have been lovely if (the Department of Health and Aged Care) had given me a ring, because up until yesterday I didn't know they were speaking about our mum," she said.

She said the family now had to sit and wait for the coroner's finding.
Family waits for verdict Herald-Sun March 10, 2000

Mar 2000 Bishop used wrong police department

AGED Care Minister Bronwyn Bishop unnecessarily delayed an investigation into the death of a nursing home resident who had been given a kerosene bath by referring it to the wrong authorities, Labor said yesterday.

Instead of reporting the death to the Victorian coroner or state police, Mrs Bishop directed her department to write to the Australian Federal Police for advice.
Bishop mix-up revealed Hobart Mercury March 10,2000

Mar 2000 The coroner approached Bishop

The rebuff came as the Federal Opposition and Victorian Attorney-General Rob Hulls attacked Mrs Bishop for not referring the death to the Victorian coroner and waiting until the coroner approached her office before providing information for his investigation.
Police Rebuff Bishop Plea The West Australian March 10, 2000

Mar 2000 Coroner to investigate 6 deaths

Federal Parliament has been told Coroner Graeme Johnstone will investigate the death of Antonietta Cucuzzella, 84, who died a few days after being given a kerosene bath at the Riverside Nursing Home.

And Mr Johnstone today revealed his preliminary investigations would include another five deaths this year at the home, at Patterson Lakes in Melbourne's south-east.
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The preliminary investigations will determine whether full coronial inquiries should be held into the deaths.
Six deaths to be investigated at Riverside nursing home Australian Associated Press March 10, 2000

Mar 2000 No consideration or information to relatives

In other developments yesterday, relatives said they were confused and shocked to learn that the Coroner will investigate the deaths of six people at Riverside this year.

"Who are they, why did they die?" Nan Coombes, 67, said. "We don't know anything about this."
Evacuees face hospital trek Sunday Herald Sun March 12, 2000

Riverside unable to cope with crisis

After the scandal broke the owners did little if anything to address the problems in the home. Further audits were conducted on the home a few days later and another after 2 weeks. The last one precipitated the home's closure. The likelihood is that management simply did not have the knowledge or the understanding needed to do anything about the situation. They should never have been in charge of a nursing home in the first place. The nursing administrator brought in by the department was given less than a week to address the myriad problems. She was critical of what happened.

Mar 2000 A second visit 2 days after first

The second full two-day audit was made on the Riverside Nursing Home this week because it had failed to comply with agency orders to improve conditions.

Nurses conducting daily random checks on the Patterson Lakes home found that fly screens had not been fitted and a freezer had not been fixed. There were privacy concerns and problems with climate control.
Kero Baths Home May Be Closed The Age March 4, 2000

Mar 2000 The immediate consequences for nurses

The nurse from Riverside said morale was at an all-time low among staff, who had called an emergency meeting on Thursday.

"The place is just chaotic," said the nurse, who asked not to be named. She said half the office staff had walked out of Riverside and the nursing staff felt as if they had been portrayed as "monsters".

"People put their relatives in nursing homes believing they will be looked after and that is what we are trying to do," the nurse said.
Nurses were shocked by kero burns. The Australian March 4, 2000

Mar 2000 Another assessment on March 1st reveals far more horror

The report that finally killed the Riverside Nursing Home reads like the outline for a Dickensian novel.

In it, one of the 57 residents treated to the infamous bath containing kerosene is said to have been dying at the time.

Cornflour was applied to the skin of residents to treat itchiness.

Bandages for wounds were so scarce that ``dressings that are leaking fluid or falling off are patched up''.

Soiled dressings were left in bathrooms; soiled bandages and towels were washed with the residents' laundry; urine-stained foam mattress overlays were stored with clean linen; fly-screens were missing; and ``there is ongoing serious risk that residents' open wounds can become flyblown and infested with maggots''.

Of 46 residents reviewed ``six have confirmed dehydration, nine others have possible dehydration, 15 have recorded increasing episodes of aggression, confusion, depression, fainting or loss of consciousness, 13 have recorded infections such as conjunctivitis, cellulitis, diarrhoea, urinary tract infections and infected wounds (and) two residents have chest infections''.

The worst single story concerns a woman who complained of pain in her left upper arm. It took a week of mis-diagnoses, suggestions her pain was simply a reaction to a `flu injection, the administration of pills, and an observation by a doctor that her right arm - the wrong one - had ``settled'' before anyone thought to order an X-ray.

Even when this unfortunate woman was treated and her arm placed in a collar-and-cuff sling, her life was put in danger and she was forced to endure even more pain because staff did not know that she had to sit up so the weight of her arm would pull the broken bone into the correct position.

Those investigating the home noted that ``the resident is frequently lying down so the bone pushes up into the shoulder causing pain and increasing the risk of fat embolus (a condition that has a very high death rate)''.

No one knows how she broke her arm. Record-keeping was so poor there was no documentation concerning the origins of the injury.

One resident fitted with a tube inserted into the stomach to maintain nutrition and hydration was seen being fed orally. There was no record to indicate whether the resident could actually swallow safely - in short, no one knew if oral feeding might lead to choking.

Medication was not stored safely. A new lock was on the medication room door, but it was often left unlocked or unattended, and medication trolleys were left unlocked and unattended in corridors and residents' rooms.

Medication was often not available and, when it was, was not administered safely - ``staff practices include administering medication that has been prescribed for another resident'', the report said.

Poor maintenance of the home hardly helped the residents' everyday comfort levels, either. Curtains and blinds were missing from west-facing windows, leaving old people sitting in the beating sun, although ``some pedestal fans are available''.

And on and on goes the report, for 19 pages - a litany of horrors.

The report was compiled by the Aged Care Accreditation Agency following an investigation of the nursing home on 29 February and 1 March.

Its damning findings became the basis for the Aged Care Department's decision yesterday to close Riverside.
Official Investigation Details A Saga Of Neglect And Abuse The Age March 7, 2000

One of the reasons why this failure in care caused such an outcry was because it exposed the inadequacy of the regulatory system and the policy behind it to the public for the first - but far from the last time. Politicians, government departments and the assessment authorities were living in a different world to residents, their families, the nurses and the Australian community. The press moved rapidly to expose them to the wider view.

Instead of acting promptly to investigate and address complaints by visiting the nursing homes the department were required to go through a cumbersome mediation process. Even worse they were unable to put someone into the home to protect residents. The homes owners had the right to appoint an administrator. We can see how far the government bent over backwards to help nursing homes who’s interests were promoted by Doug Moran and his mates.

We should not blame the agency and its staff for the failures in the system. They were constrained by the way it was set up - and were committed to an unrealistic process. They had to cope with coalition governments which deliberately legislated to allow businesses to compromise care (eg reduce staffing below safe levels) and then created a system which protected those who took advantage of this. Those same politicians then blamed the agency for what happened.

Feb 2000 Home to nominate an acceptable administrator

The Melbourne nursing home which bathed residents in kerosene has yet to nominate an administrator to run the home, the Minister for Aged Care, Mrs Bishop, said last night.

Last Tuesday the Government ordered that an administrator be put into the Riverside Nursing Home.

Under the legislation the home has the right to name the administrator, who must be approved by the Health and Aged Care Department.

Mrs Bishop said the act gave the home 14 days to nominate someone.
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The department last week withdrew the home's provider status and then suspended the withdrawal on condition that an administrator was appointed.
Nominate Administrator Or Risk Licence, Nursing Home Told Sydney Morning Herald February 28, 2000

Feb 2000 Alarm bells did not ring

The Australian Medical Association aged care expert Dr Gerald Segal noted the suspected presence of scabies should have rung alarm bells about conditions at the home.
Even Dickens would be appalled. Courier Mail February 26, 2000

Feb 2000 "Reforms" not working