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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 2 - Statement of Complaint:

Statement of Complaint:

1. On admission to St Mary's on Monday, 12 December, 2005, Mrs Kelly's skin was assessed as being intact, although because of her age, it was tissue paper like, dry and discoloured. By Wednesday, 14 December, her heels and sacrum were noted to be red. When the complainant brought her mother home from St Mary's on the afternoon of Thursday 15 December, she observed two large blisters on her mother's sacrum, a large blister on her right heel and a smaller one on her left heel. The condition of the blister on Mrs Kelly's right heel did not improve, was subsequently tested positive for MRSA, and had to be debrided on three occasions.

2. The complainant has continuously alleged that she was never advised about her mother's red pressure areas or blisters by the Clinical Nurse Manager in St Mary's. Their existence was verified by Mrs Kelly's Home Help on Thursday evening, 15 December, 2005, and by the Public Health Nurse who visited her on Friday, 16 December, 2005. The complainant had telephoned the Director of Nursing on Thursday 15 December, 2005 to advise her regarding her mother's condition and to make a complaint.

3. The following factors were alleged by the complainant to have contributed to the development of her mother's pressure areas:

* Inadequate nutrition and hydration throughout the period from Tuesday morning through to Wednesday afternoon when her mother was commenced on a subcutaneous saline drip;

 * Refusal by the nursing staff to allow either the complainant or her sister to feed their mother with a syringe from Tuesday morning until she was taken home;

* Failure to have her mother assessed by a Speech and Language Therapist with regard to her swallowing difficulties, although a referral had been made by the resident Medical Officer on Tuesday morning.

* Failure to take her mother out of bed because seating could not be provided by the Occupational Therapy Department;

* Failure to turn her mother every two hours to relieve her pressure areas as was the norm at home;

* Failure to administer her mother's medication in accordance with that documented by the complainant and prescribed by her regular GP;

* Failure to measure her mother's urinary output on Tuesday 13 December, 2005, or to test it when, on observation, it became concentrated;

* Failure to carry out blood tests when her mother developed a high temperature;

* Failure to advise the complainant of her mother's condition despite the fact that she had left her mobile phone number with hospital staff requesting to be contacted if they experienced any difficulties with regard to her mother's care.

4. Mrs Moore received a written reply to her complaint in January, 2006 from the General Manager, which acknowledged the shortcomings in her mother's care, and invited her to make contact if she wished to discuss the issues further. Mrs Moore alleges that she did telephone the General Manager on a number of occasions after that, but she did not return her calls. When a meeting with hospital staff was arranged, to include the Clinical Nurse Manager, the latter decided at the last minute not to attend. Mrs Moore, having arrived for the meeting, considered it pointless for the meeting to proceed on being informed that the Clinical Nurse Manager would not be there.

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Issues with regard to MRSA:

Although this issue did not form part of the Statement of Complaint, Mrs Moore had sought information in her original letter as to whether nursing staff were taking precautions to avoid the spread of MRSA in St Mary's, and stated that there was no handwash at the sink when she went to wash her hands. This issue is included in Chapter 4 of this report under the Analysis Section.

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