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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

Chapter 1 - Background

Background

(The complainant's name and that of her late mother have been changed in this Report to protect their identities).

The complainant, Mrs Jane Moore, (a qualified nurse), looked after her elderly mother, (Mrs Ann Kelly ) for five years at home before her death in March, 2006. Her mother had suffered a stroke in 2001, which had left her physically and mentally incapacitated. She was totally dependent and was unable to communicate her needs to others. With regard to her ability to take food, Mrs Kelly had difficulties in swallowing, and her food was therefore, fed to her by means of a syringe at home. Her medication was also administered in this manner having been crushed into her food.

Mrs Moore received outside assistance in caring for her mother from a home help on week days, one hour in the morning to help get her mother up, washed and dressed, and for one hour in the evening to help put her mother to bed. In December 2005, for the first time since her mother had suffered the stroke, Mrs Moore (for family reasons) sought to avail of one week's respite care for her mother in St Mary's Care Centre, Mullingar, which is a public nursing home run by the Health Service Executive (HSE).

Mrs Kelly was admitted to St Mary's on the afternoon of Monday, 12 December, 2005, but her daughter took her home just three days later, because she was unhappy with the level of care afforded to her mother. On admission to St Mary's, Mrs Moore provided a full and detailed account of her mother's needs to the nursing staff. This included information with regard to her mother's diet, medication, daily routine and caring needs. She also provided a sample dinner to show the correct consistency of food, a selection of fortified drinks which her mother normally took at home, and sufficient changes of clothes for her mother whom she had asked to be taken out of bed each day.

According to the complainant, during the five year period she had cared for her mother, Mrs Kelly had never suffered from bedsores. However, on taking her mother home from St Mary's on Thursday afternoon (15 December), she noticed that she had developed large black blisters on her sacrum (base of her spine), and on both her heels. In addition, she said that her mother was dehydrated and had developed a urinary tract infection, which was diagnosed and treated by a doctor from Midoc (an out-of-hours service provided by GPs in partnership with the HSE) whom the complainant had telephoned on her return home.

Following this medical assessment, the complainant immediately telephoned the Director of Nursing in St Mary's to express her upset and anger at her mother's condition, whom she felt had been neglected. She outlined a number of issues regarding her mother's care which caused her concern. These included inadequate levels of nutrition, hydration, medication dosages and the fact that her mother had not been taken out of bed for the duration of her stay. The complainant also felt that her mother had not been turned sufficiently, and appeared to be in the same position in the bed on Thursday as when she had left her. The Director of Nursing assured Mrs Moore that a full investigation would be carried out, and requested her to forward her complaint in writing to the General Manager, Community Care Services, HSE, so that each issue could be fully examined.

While the blisters on her mother's sacrum and left heel did ultimately improve, the blister on her right heel proved resistant to treatment, and subsequently tested positive for MRSA in January, 2006. Her mother had to have her right heel debrided (dead skin removed) on three occasions in Mullingar General Hospital. Mrs Kelly subsequently developed pneumonia and died on 24 March, 2006.

Initial response by HSE to Mrs Moore's complaint:

In response to Mrs Moore's written letter of complaint (dated 17/12/05), she received a reply one month later from the General Manager, Community Care Services, HSE, thanking her for bringing her concerns to the attention of the HSE. In her letter, the General Manager acknowledged that the level of care afforded to Mrs Moore's mother, following her admission to St Mary's Care Centre, fell short of the standards of excellence to which management and staff continually strived to achieve. She said that the complaint had led her to initiate a review of existing protocols and procedures in relation to patient care.

Following the General Manager's decision to initiate a review of existing procedures, she referred the incident to the HSE Healthcare Risk Management Service, which carried out a desk top examination of all written records and documentation pertaining to the patient's care. All staff involved in the care of Mrs Kelly were interviewed as part of the review. A review team was established comprised of the General Manager, the Community Services Manager, the Director of Nursing, the Speech and Language Therapy Manager, the Medical Officer, the Director of Public Health Nursing, and representatives from Risk Management.

On completion of the review, a report was produced which documented details of the care afforded to the complainant's mother in chronological order. This report was based on the interview notes as well as information obtained from Mrs Kelly's medical and nursing records. It also examined the adequacy of existing control measures at St Mary's, and made a number of recommendations with regard to required new control measures for the Centre. (see Chapter 5)

On 27 March, 2006, (three days after Mrs Kelly passed away) the General Manager wrote to Mrs Moore advising her that the review had been completed, and that a copy of the final report would be sent to her the following week. One month later, Mrs Moore contacted my Office stating that she had tried to contact the General Manager, but that she was never available, and was not returning her calls. She stated that she had not received a copy of the report, as promised. Following contact from my Office, the report was subsequently forwarded to Mrs Moore by the Community Services Manager on 11 May, 2006, for her comments. In response, she, along with her sister, sought a meeting with the staff directly involved in their late mother's care, including the Clinical Nurse Manager, who had overall responsibility for the management of the ward in which Mrs Kelly had been placed. This meeting was scheduled to take place on 29 June, 2006, and the complainant was advised that the Clinical Nurse Manager would be present. However, on that day the Clinical Nurse Manager decided that she would not attend the meeting as she feared it might become confrontational. The complainant, therefore, felt that there was no point in proceeding with the meeting as many of her questions would have been directed at the Clinical Nurse Manager who had been on duty during the most critical time of her mother's care.

Contact with my Office/action taken:

Mrs Moore originally contacted my office towards the end of April, 2006, indicating that she felt her complaint was not being taken seriously by the HSE, as she was getting no response from the people who were dealing with it. She stated that she rang the General Manager on numerous occasions, and called into her office, but she was never available. As mentioned previously, she did subsequently receive a copy of the report in relation to her mother's care on 11 May, 2006, and a meeting was arranged with the staff involved in June. However, Mrs Moore felt let down by the HSE when the Clinical Nurse Manager failed to attend the meeting, as arranged. She felt unable to pursue her complaint further. It was agreed by the HSE and the complainant that my Office would examine the complaint at that stage.

Mrs Moore submitted a list of questions to my Office regarding her late mother's care which she felt needed to be addressed. My investigative staff, in an effort to obtain answers to these questions and to bring resolution to the complaint, met and discussed the primary issues of concern with the key members of staff involved in the care of the complainant's mother. Discussions also took place with the Director of Nursing and the Risk Manager attached to St Mary's.

In addition, telephone contact was made with:

• the complainant's sister, who had visited her mother for a number of hours on the Tuesday and Wednesday afternoon during the period of her mother's respite stay;
• the woman who provided home help services and who attended her mother on the evening she returned home;
• the Public Health Nurse who visited her the following morning; and
• her General Practitioner.

On foot of this, the preliminary views of my Office were conveyed to Mrs Moore in writing based on the responses provided by the relevant staff in St Mary's to the issues raised. She was invited to comment on them.

Decision to hold a Formal Investigation:

Mrs Moore felt that, while the letter from my Office had clarified a number of areas, she continued to be dissatisfied in relation to some issues. Given the serious nature of these issues, I decided to undertake a formal investigation of the case under the provisions of Section 4 (2) of the Ombudsman Act, 1980. The Statement of Complaint (see Chapter 2) sets out the issues remaining in dispute. It, together with a copy of my Office's letter containing the questions and responses which had issued to Mrs Moore, were forwarded to the Community Services Manager, to allow the staff involved an opportunity to make further comments (see Chapter 3).

Apart from the concerns about the standard of care provided to Mrs Kelly in St Mary's, the two critical issues dealt with in the Statement of Complaint were:

1) the circumstances of the assessment of the patient's capacity to swallow food (into which her medication was crushed) which is normally undertaken by a Speech & Language Therapist; and

2) the allegations by the complainant that she was never advised about the condition of her mother's pressure areas before she took her home from the Care Centre.

In accordance with agreed procedures, I prepared an initial draft report of my investigation of the complaint, extracts from which I made available to relevant HSE staff. Their comments, where appropriate, have been incorporated in this report. A copy of the final draft report was sent to the Local Health Manager for the HSE - Dublin Mid-Leinster region, and his response is attached at Appendix A. His principal comments and my responses to them are incorporated in the body of the report.

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