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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 3 - HSE's response to the Statement of Complaint

HSE's response to the Statement of Complaint:

Nursing:

A member of the nursing staff indicated that it was her understanding, following her initial contact with the Speech and Language Therapist on Tuesday 13 December, 2005, that she would return to the ward the following day to assess Mrs Kelly, and not just to collect the Medical Officer's signed referral letter. She stated that she had alerted the Speech and Language Therapist to the fact that the patient was being syringe fed at home, and that this practice could not be continued in the Care Centre. This, she said, would have clearly indicated that there was an urgent need for assessment. She felt that this was at variance with what the Speech and Language Therapist had said in her response.

In relation to Mrs Kelly's pressure areas, it was stated that she had no pressure sores on discharge, but that her pressure areas were red.

Speech and Language Therapist:

The Speech and Language Therapist remarked that, in accordance with agreed procedures, her duty of care to the patient commenced on acceptance of the medical referral. In this instance, the referral form had not been signed by the Medical Officer when he requested the assessment, and she stated that she could not, therefore, accept it. She commented that the Professional Standards for Speech and Language Therapists, the Local Department Referral Policy, and Standard Operational Procedures all state that a written referral to the Speech and Language Therapist is required for dysphagia (swallowing difficulties) and should be signed by the medical/surgical team/GP. She said that she recalled that the appropriateness of syringe feeding was the issue raised at the time, but that no sense of urgency was conveyed to her by the nurse who contacted her in relation to carrying out a swallowing assessment. She noted that while Mrs Kelly's daughter had provided specific details to nursing staff in relation to her mother's swallowing impairment and necessary food modification, none of this information had been conveyed to her.

Due to other work commitments, the Speech and Language Therapist did not get back to the ward on Wednesday, 14 December, 2005 as previously arranged. She said that no messages, however, were left for her on her work mobile number or her landline, which has a voicemail facility, indicating the need to prioritise this patient. Neither was any message left with the multi-disciplinary therapy team at St Mary's for her attention. She stated that she was not made aware of the changing medical status of this patient, which would indicate the need to prioritise her case.

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