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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, Mulingar, Co Westmeath

Foreward

FOREWORD

This report highlights serious inadequacies in the care given to a woman in her late eighties who was admitted to a HSE nursing home for respite care in December 2005. My investigation under the Ombudsman Act 1980 found a series of communications and other failures on the part of the nursing home and its professional staff which had serious negative consequences for the elderly patient and her family. The level of care was so unsatisfactory that the patient's family took their mother home from the nursing home after three days. My investigation concludes that these failures in patient care contributed, amongst other things, to the patient developing pressure sores and blisters which proved troublesome and difficult to treat. And when the patient's daughter complained about these failures in care, there were significant shortcomings in the HSE's handling of the complaint. Indeed, these shortcomings added to the daughter's sense of grievance and compounded the shortcomings in the level of care provided.

The elderly woman had suffered a stroke in 2001 and had been cared for at home by her daughter since then. The respite stay was the first occasion since the stroke on which the woman had been cared for away from home. In her complaint to my Office the patient's daughter, who was herself a trained nurse, identified a number of specific failures in care, including:

• that appropriate feeding arrangements for her mother had not been followed;
• that her mother had become dehydrated while in the nursing home;
• that her mother's medication had not been administered properly while in the nursing home;
• that on her return home from the nursing home her mother was found to have pressure sores and blisters (which the daughter attributed to inadequate care in the nursing home) as well as a urinary tract infection; and
• that the nursing home had failed to tell her, on the day of discharge, that her mother had developed these pressure sores and blisters.

My investigation found that, broadly speaking, the complaint as made was well founded. I found that there were shortcomings in patient care - involving staff in the medical, nursing and speech and language therapy areas - which contributed to the development of pressure sores. In the area of communications, there was a failure to contact the daughter by phone (as she had suggested) when difficulties arose and a failure to inform the daughter of her mother's pressure sores at the point when the mother was being taken home.

Arising from my investigation, I made a number of recommendations to the HSE, including:

• that the nursing home develop written protocols on the referral of patients (both respite and long-stay) for para-medical services such as speech and language therapy;
• that staff have on-going education and training to ensure effective communication both internally and with patients and their families;
• that the nursing home develop protocols for the admission of respite patients with a view to ensuring that all of the patient's needs are identified and provided for in a timely fashion;
• that records be kept of any difficulties in the administration of medication to patients and that such records should show the amount of medication administered and consumed;
• that in this particular case the HSE make a "time and trouble" payment of €3,000 to the complainant in recognition of the effort involved in pursuing her complaint.

I am happy to say that the HSE has accepted these recommendations and has produced an Action Plan (Appendix B to this report) for their implementation.

There are valuable lessons to be learned from this investigation, both in terms of patient care and in terms of dealing with complaints concerning patient care. I hope that the HSE, and all in the public health system involved in providing care for the elderly, will be open to learning these lessons.

Emily O'Reilly

Ombudsman

December, 2008

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