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A Report by the Ombudsman in relation to a complaint about the care and treatment of a patient at St Mary's Care Centre, Mullingar, Westmeath.

Date released: 15.12.2008

• Ombudsman Emily O'Reilly publishes Investigation Report about the unacceptable standard of care and treatment of an elderly woman admitted for respite care in a HSE public nursing home in Mullingar.
• Says lessons need to be learned from failure to provide appropriate care in feeding and ensuring adequate hydration for the patient who had been physically and mentally incapacitated as a result of a stroke.
• HSE acknowledges deficiencies and commits to implementing Ombudsman's recommendations in full.

The Ombudsman, Emily O'Reilly, today (Monday, 15 December 2008) published her report into the care and treatment of an elderly woman availing of respite care in St. Mary's Care Centre, Mullingar, a Health Service Executive (HSE) public nursing home.

The complainant in this case was the daughter of an 88 year-old woman, who had been physically and mentally incapacitated as a result of a stroke. The daughter had arranged one week's respite care for her mother in St Mary's Care Centre in Mullingar, Co. Westmeath. However the daughter, herself a trained nurse, was extremely dissatisfied with the care her mother had received; in fact, she had taken her mother home from the nursing home after only three days when she saw what she felt was a rapid deterioration in her mother's condition. Subsequently, in April 2006, she complained to the Ombudsman about the poor care given to her mother.

The complainant was also unhappy with the manner in which her initial complaint to the HSE had been handled; she felt that the failure of the HSE to deal properly with her complaint added to her sense of grievance and compounded the shortcomings in the level of care provided.

The Ombudsman's investigation found that the complaint as made was well founded. The Ombudsman is publishing the report as it should be of interest not only to members of the public, but also to healthcare professionals and support staff working in every corner of healthcare across the country.

Commenting on the report findings, the Ombudsman said:

"In this case, a daughter had dedicated several years of her life to caring for her mother, who was totally dependent, at home. With a degree of apprehension, she decided to avail of a one-week period of respite, so that she could attend to other family matters. She placed her trust in the system that her mother would be cared for to the same standard that she was cared for at home, even though her mother had very complex needs. Very regrettably, the care received was far from what she could reasonably have expected. My investigation showed that the nursing home failed to ensure that even the patient's most basic needs were catered for, including being adequately fed and hydrated."

The investigation report details failures to provide urgent input from relevant members of the home's multi-disciplinary team. It also highlights the failure to meet the patient's need for adequate food, fluids and appropriate care of vulnerable areas of skin. When her daughter took her home after three days, the patient was found to have pressure sores and blisters which had not been there on admission to the home.

The report highlights the failure of nursing home staff to contact the daughter to say that her mother's condition had deteriorated following admission to the home. It draws attention also to failures on the part of the HSE in its handling of the complaint made subsequently by the daughter; in particular, the Ombudsman is critical of the failure of the HSE to arrange a promised meeting for the complainant with all of the key staff involved in her mother's care.

The HSE has accepted all the recommendations of the report and has developed a comprehensive action plan to implement them. Many of the recommendations have been addressed already while some others are currently being progressed. The Ombudsman has said that the HSE must be commended for acknowledging the deficiencies in its systems and for agreeing changes and improvements that will have long-term effect not only in the Midlands region but, hopefully, throughout the country.

The Ombudsman is particularly appreciative of a thank-you letter received from the complainant after she had been told the results of the investigation. In that letter, quoted here with her permission, the complainant said:

"Now I feel I have achieved something for her [the patient], because I do blame myself for letting her go into respite care. I often think if only I did not let her go. Please God, I will move on now......"

In response, the Ombudsman commented,

"I was genuinely gratified that the investigation upholding the complaint, and the complainant's satisfaction with the result in this distressing and tragic case, has helped bring some closure for her and her family."

The Ombudsman notes that this case is one of a growing number of complaints received by her Office regarding care and treatment received in publicly funded healthcare agencies; in several of these cases she has recommended redress as well as recommendations involving changes to hospital protocols and procedures.

Overall, the Ombudsman has said:

"There are valuable lessons to be learned from this investigation, particularly in relation to delivering patient care to older and more vulnerable people. There are also important issues raised regarding how to deal with complaints in relation to patient care and accountability for such care. I hope that the HSE, and all those in the public health system engaged in providing care for older people, will be open to learning these lessons so that the experience of my complainant and her mother, in this case, will not be repeated."

ENDS

 

 

 

 

Editors' Note

Ombudsman's recommendations:

1. St Mary's Care Centre, in conjunction with the Health Service Executive - Dublin Mid-Leinster to:

• Develop written protocols on the referral of patients (both respite and long-stay patients) for all para-medical services, including speech and language therapy assessments. Protocols should be understood and implemented by all members of staff, including medical staff, and new or temporary staff in the Centre. Also, protocols should provide for urgent referrals when regular para-medical staff members are unavailable;
• Provide ongoing education and training programmes for all staff members to ensure that they communicate effectively with each other, with the elderly residents, and their families;
• Revise and develop protocols for the admission of a person for respite care, particularly for first respite admissions, to ensure that all of the patient's needs are identified and provided for in a timely way. Consideration to be given to meeting with the patient's carer/s in advance and having the patient examined by the medical officer on day of admission;
• Revise protocols for nursing staff to reflect best practice with regard to the turning of patients who are susceptible to developing pressure sores;
• Develop protocols for nursing staff with regard to the seeking of advice from the Director of Nursing on crisis intervention and develop a policy regarding the transfer of residents to acute hospital services;
• Provide education and training for all nursing staff in caring for residents who may be unable to communicate their own needs;
• Arrange for nursing staff to ensure that the wishes of residents and their relatives are documented, listened to and acted upon, and that carers/relatives are kept informed fully with regard to their relatives' condition. If any difficulties arise with regard to the management of any patient, their principal carer, or next of kin, should be immediately advised;
• Record difficulties with regard to the administration of medication to patients in the nursing records and on the prescription sheet, and these records should accurately reflect the amount of medication administered and consumed;
• Review its procedures to ensure that all significant observations on a patient's condition are recorded in the nursing records, and that entries accurately reflect the interaction between nurse and patient and include important interactions with his/her carer or relative and that,
• The general manager should review the complaints handling process to ensure that complainants are kept informed fully and updated as to the status of their complaint and ensure that there is a system in place which will guarantee proper engagement between a complainant and HSE staff.

2. HSE should:

• Explore with the relevant stakeholders the possibility of introducing guidelines for medical officers with regard to the supply of medication for patients who are leaving hospital or nursing home care, to ensure continuity of care until they can arrange to be seen by their own General Practitioner;

3. Dublin Mid-Leinster HSE should:

• Make a ‘time and trouble’ payment of €3,000 to the complainant in recognition of the effort expended by her in the pursuit of her complaint.

The full text of the case is available from:- www.ombudsman.ie

 

 Further information is available from:- Fintan Butler, Senior Investigator, Tel: 01 6395650 email: fintan_butler@ombudsman.gov.ie or Patsy Fitzsimons, Investigator, Tel 01 639 5637 email: patsy_fitzsimons@ombudsman.gov.ie

For media inquiries contact:- Dave Glynn, Head of Communications, Tel: 01 6395714, or 087 2361884 email: david_glynn@ombudsman.gov.ie

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