Basically, I talked to the family. I reviewed the medical chart myself. He was being humiliated by staff. They would leave the windows open, complain when they had to change him. He couldn't get in touch with his family that often. He would go hungry when they cleared his food trays. In this context, he developed shortness of breath that wasn't comprehensively assessed. He would become so confused that his oxygen, when it slipped off his face...they had to cancel his second assessment.
The second assessor told the family that she would have to go off the first assessment. So he received MAID in a very sloppy fashion, without proper diagnosis. As I said, the family doctor was never consulted and the diagnosis was not confirmed in hospital or through collateral history taking.