99-Year-Old Dementia Patient’s Preventable Death Highlights Rest Home Safety Concerns

The death of a 99-year-old dementia patient following an assault by a fellow resident at an assisted living facility in Hamilton, New Zealand, has brought to light serious systemic failures in resident care. A coroner’s report revealed the death was preventable, stemming from a failure to adequately manage a resident with a history of aggressive behavior.

Details of the Incident

Leonard Ralph Hewgill died in Waikato Hospital on October 6, 2018, three days after being attacked in his bedroom at the Hilda Ross Special Care Unit, a 40-bedroom facility specializing in dementia care. The assailant, 71-year-old Ike Cowley, also suffered from dementia, specifically Parkinson’s-related dementia. According to Coroner Louella Dunn’s report, Cowley entered Hewgill’s room around 8 p.m. And assaulted him. Staff intervened, but not before Hewgill sustained a head injury.

During the assault, Cowley reportedly threatened Hewgill, stating, “I’m going to kill him” and “let him die, let him die.” Hewgill, though initially unconscious, told care workers, “he’s hitting me.” Cowley continued to exhibit agitated behavior after leaving Hewgill’s room and subsequently assaulted another resident.

54 Prior Warnings Ignored

The coroner’s investigation revealed a disturbing pattern of ignored warning signs. Prior to the fatal assault, Cowley had been involved in 54 reported incidents of challenging behavior between 2016 and October 2018. These incidents included physical aggression towards both staff and other residents. Despite this extensive history, the facility failed to develop a comprehensive behavioral management plan to de-escalate situations or prevent further violence. Independent assessments found that the facility minimized the severity of these incidents rather than recognizing them as escalating risks.

Criminal Proceedings and Legal Outcome

Following the assault, Cowley was charged with manslaughter and wounding with intent to injure. Though, due to his dementia, he was deemed unfit to stand trial and was dealt with under the Criminal Procedure (Mentally Impaired Persons) Act 2003. The charges were ultimately stayed, and Cowley was released.

Coroner’s Findings and Recommendations

Coroner Dunn concluded that Hewgill’s death was preventable and highlighted deficiencies in Hilda Ross’ processes for managing residents with challenging behaviors. Specifically, the coroner cited a lack of adequate documentation to identify and track triggering behaviors, as well as insufficient staff training on de-escalation techniques.

The coroner issued six safety recommendations to Ryman Healthcare, the operator of Hilda Ross, focusing on strengthening documentation processes and enhancing training programs for staff. Ryman Healthcare stated that they implemented these changes by 2019 and expressed their deep sadness over Hewgill’s death.

Marsha Cadman, Ryman Healthcare chief operating officer, stated, “Following the incident, we immediately launched an investigation, with two independent experts…This resulted in changes across all our dementia care units, reinforcing our commitment to providing safe, respectful, high-quality care.”

Call for National Policy

Hewgill’s family is advocating for a national, legally enforceable policy regarding the care management of aggressive residents with dementia, aiming to prevent similar tragedies in the future.