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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 6 - Findings

Findings:

It is my finding that the late Mrs Kelly received inadequate patient care during her period of respite care in St Mary's Care Centre, Mullingar from 12 December, 2005 to 15 December, 2005. These inadequacies contributed to the development of dark red pressure sores and ultimately black blisters on her sacrum and heels. These are outlined as follows:

• Failure by the Medical Officer to sign the referral form on Tuesday 13 December requesting the Speech and Language Therapist to carry out an assessment of Mrs Kelly's swallowing difficulties (in accordance with the policy in St Mary's), on being advised by nursing staff that she was syringe-fed at home;
• Failure by the Speech and Language Therapist to return to the ward on Wednesday 14 December to collect the signed referral, as arranged with nursing staff;
• Failure by the Clinical Nurse Manager on Wednesday afternoon to ensure that an urgent message was left for the Speech and Language Therapist either on her landline, or her mobile phone, seeking her urgent assistance with regard to Mrs Kelly's feeding difficulties, or to seek urgent assistance from the Speech Therapist in the acute hospital, which was the custom when the regular Speech and Language Therapist was absent on leave;
• Failure by nursing staff, as a result of the assessment not being carried out, to provide adequate nutrition, hydration and medication to Mrs Kelly (not withstanding that the nursing records had been signed off that she had received all her medication) throughout her stay by refusing to allow a family member who was present to feed her pending completion of the Speech & Language Therapist's assessment;
• Failure by nursing staff to alter Mrs Kelly's turning regime once they noticed that her pressure areas had become dark red in colour;
• Failure by the Occupational Therapy Department to provide seating for Mrs Kelly to enable her to sit out of bed;

In the area of communications, my findings are as follows:

• Failure by nursing staff to contact the complainant by phone, as she had requested, to advise her of any difficulties they had encountered in caring for her mother, and in relation to her mother's deteriorating condition;
• Failure by the Clinical Nurse Manager to advise the complainant of her mother's deteriorating pressure areas when she arrived to take her mother home;
• Failure by the General Manager to respond to Mrs Moore's telephone calls or to make contact with Mrs Moore over a two month period, (from 17 January, 2006 until 27 March, 2006) having written to her, inviting her to discuss the issues with her further, if she so wished. In addition, failure by the General Manager to forward a copy of the Review Group's final report to Mrs Moore as promised within the specified timeframe;
• Failure by the Clinical Nurse Manager to give due notice that she would not be attending the meeting with the complainant and her sister, as arranged.

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