A 20-year-old man with a rare genetic condition died after care staff failed to recognise that he was seriously ill, a Health and Disability Commission (HDC) report has found.
The man, known as Mr B, lived in a secure residential facility for people with intellectual disabilities. Staff did not notice that his bowel had ruptured, and medical help was not sought in time.
Mr B had Prader-Willi Syndrome, which requires close supervision. The report found staff failed to properly monitor his health, manage his condition, or respond to clear warning signs when he became unwell.
He died in May 2023 after being taken to hospital with diabetic ketoacidosis, caused by undiagnosed diabetes and sepsis from the bowel rupture, which had gone unnoticed for about a week.
In the days before his hospitalisation, Mr B showed signs such as loss of appetite, abdominal pain, dizziness, extreme thirst and weakness, but these were not treated as urgent.
The Commission found serious care failures, including poor staff training, weak supervision, poor handovers between shifts and over-reliance on Mr B to report his own symptoms.
Deputy Commissioner Rose Wall said Mr B was not properly supervised or cared for and that his death was likely preventable.
The care provider accepted the findings, apologised to the family and said it has since improved staffing, training and care systems.