A frail elderly woman died following a “significant” heart attack and stroke after her support service failed to carry out safety checks, the health watchdog found.

In a report released by Deputy Health and Disability Commissioner Rose Wall on Monday, home-based healthcare and support service Access Community Health was found in breach of the patients’ rights code for failing to have adequate procedures in place when checking on clients.

At the time of events in 2018, the woman, referred to as Mrs A, lived by herself. She was blind in one eye and had chronic obstructive pulmonary disease, impaired balance – making her a high falls risk – and aortic valve stenosis – narrowing of the aorta valve in the heart, reducing blood flow to the body.

Access support workers were responsible for helping Mrs A twice-daily with personal care, oversight of her medication, home management and safety checks to ensure she was safe in her home.

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At 8.10am on the day in question, a support worker went to Mrs A’s house to find she was not answering the door.

The support worker notified the Access call-centre, who attempted to phone Mrs A’s house and both her next-of-kin as part of its “Client Not Home” process, but the calls went unanswered.

A call was made to the local hospital, but Mrs A was not a patient, so the support worker was advised to move on.

This process happened twice more – at 4.13pm and at 10am the following morning – with the same results, the report stated.

At 11am the following day, a support worker gained access to her home using a neighbour’s key, and found her lying in bed “cold and unresponsive” having suffered a “significant” serious heart attack (STEMI) and stroke.

She was taken to hospital by ambulance, where she died the next day.

Wall found that by failing to have an adequate process for staff to follow in the event a client was not at home or answering the door, Access failed to ensure Mrs A was safe and denied her the opportunity for earlier medical intervention, the report stated.

She was critical that Access’ “Client Not Home” policy lacked an escalation mechanism, that there was no differentiated process for clients at different levels of risk and did not align with sector standards.

Wall recommended Access Community Health apologise to the woman’s family, which it has since done, the report stated.

She also recommended Access develop an alert system for clients who require safety checks, and update its processes to ensure important information for emergencies – such as the location of spare keys – is recorded.

Wall also stated Access should provide further training to call-centre support staff on its new “Client Not Home” process.

Access Community Health has been approached for comment.