Shona and Emily Strudwicke feared other families would go through the same "nightmare" they had been through.
"To watch this abuse happen to someone you love, to someone that worked hard ... is very hard," Shona Strudwicke said.
"For me, to spend her last three months trying to get the care promised and paid for was exhausting.
"For them to have trashed out our last special times together is unforgivable."
Mrs Strudwicke lodged a complaint with the Health Disability Commission (HDC) on November 2021 about the care her mother Joyce Robertson received during her time as a resident at a Presbyterian Support care home between July and September of this same year.
During this time, the family went through what they described as a nightmare.
There was poor documentation of Mrs Robertson’s fluid balance records, she was not weighed regularly, nor was there guidance on managing her fluid intake as recommended in her hospital’s discharge notes.
Mrs Strudwicke also said they had to deal with untrained staff and one day she found a nurse getting ready to administer insulin to her mum which was not prescribed.
They also had to battle for her to provide a basic-level care such as dress her with her own clothes, cleaning her and taking her to the bathroom which often exceeded a 20-minute wait.
"[It was] one of the hardest time of our lives."
Last year, Health and Disability Commissioner Carolyn Cooper found Presbyterian Support Southland has breached its rights and did not provide an appropriate standard of care to Mrs Robertson.
She made a range of recommendations which included a formal apology, a focus on education and staff training and to put in place better processes to ensure residents’ needs were met in a timelier manner.
However, Mrs Strudwicke felt this did not make justice to what her beloved mum went through.
Not only did the investigation take more than three years to be resolved, but she believed there was no follow-up with things like random audits to ensure the correct processes were being followed.
She also felt HDC decided to look into some parts of her complaint but left other parts without investigation.
Her daughter Emily agreed and said they never received a formal apology from the Presbyterian Support Southland.
"The health and age care system is beyond broken," Emily said.
A HDC spokeswoman said yesterday they undertook an investigation of the care provided and held the provider to account by finding them in breach of the code that was "a significant step which is taken seriously by providers".
The commissioner made a number of recommendations to improve the standard of care and all those were met in October 2024.
"A copy of our final decision report was also provided to HealthCERT who are responsible for the ongoing monitoring of residential aged care homes to ensure they are providing a safe and reasonable level of care."
They acknowledged their investigation process could be lengthy and apologised to Mrs Strudwicke for the distress this has caused her — however, she said in the last five years, there was a 52% increase in complaints.
While 70% of complaints were resolved within six months, this significant volume has put the HDC under pressure and caused delays in more complex complaints.
"Mrs Studwicke has been informed that if she was unhappy with HDC’s decision she may make a complaint to the Ombudsman."
While Presbyterian Support Southland director Carol Riddle said they have taken all the recommendations from the HDC seriously, and could reassure Mrs Strudwicke processes were changed to ensure all of those were addressed.
"At certification audit there were no findings and Peacehaven achieved a 4-year certification period and two continuous improvements — one for clinical management of our residents."
She guaranteed a formal apology letter was sent to Mrs Strudwicke via the HDC on June last year.
Mrs Riddle said the care and wellbeing of their residents was their top priority and that the complaint from Mrs Strudwicke was raised in 2021 during the COVID-19 pandemic when their nursing team decreased from 45 nurses to 13.
"We acknowledge this does not excuse shortfalls in care but provides context to an extremely challenging time for our sector."
