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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

Appendix A- HSE's response to the draft Report

Local Health Manager

Primary, Community & Continuing Care

Longford/Westmeath Primary Care Unit

St Loman's Hospital

ATH CLIATH LAR-LAIGHEAN DUBLIN MID-LEINSTER 

Mullingar

Co Westmeath

 

Telephone: (044) 93 95508 Fax: (044) 93 84431

Email: joseph.ruane@mailq.hse.le

11th April 2008

 Ref. LHO/BM

 Mr. Pat Whelan

Director General

Office of the Ombudsman

18, Lower Leeson Street

Dublin 2

 Re: Draft Investigation Report - Mrs June Moore.

 

Dear Mr. Whelan,

I wish to acknowledge receipt of the above report and outlined below are my comments and observations on the report, following discussion with my colleagues involved in the investigation.

Throughout the report, great emphasis is placed on the fact that Mrs Kelly was not syringe fed during her short stay in St. Mary's Care Centre. However, it is important to note that, upon admission, staff were advised that she was "sometimes" fed by means of a syringe at home and was not, therefore, totally dependent on food intake via syringe. She was able to take very small quantities of food from a spoon and this was the method used by nursing staff at St. Mary's Care Centre to give food and medication to Mrs Kelly.

The report does not comment upon that fact that Mrs Kelly was very ill upon admission and was already suffering from a respiratory tract infection. Because her chest was very congested, concerns were raised about the appropriateness of syringe feeding and the high risk of her aspirating during this process. It is not clear from the report that other interventions were taking place to ensure that Mrs Kelly's condition did not deteriorate. A Pro-2000 mattress was ordered immediately upon admission and was in place on the Monday evening. A physiotherapy referral was made and Mrs Kelly received chest physiotherapy on the ward. She was receiving sub-cutaneous fluids from Wednesday, thereby ensuring that her hydration levels were maintained. Oral antibiotics were given to treat her chest infection and she was also treated by the chiropodist.

When dealing with the matter of Mrs Kelly's pressure sores, the report states "Mrs Kelly subsequently developed pneumonia-septicaemia, and died on 24 March 2006". An initial reading of this statement could lead to the conclusion that these pressure sores directly contributed to Mrs Kelly's death. In actual fact, Mrs Kelly died of pneumonia, which she had for two to three weeks prior to her death. Cerebrovascular accident and ischemic heart disease were identified as Antecedent Cause I and 2 respectively. There is no mention on her death certificate of septicaemia. Mrs Kelly died more than three months after her stay in St. Mary's Care Centre, at the age of 89 years.

On the matter of informing Mrs Moore about her mother's pressure areas, the Clinical Nurse Manager and staff nurse have both confirmed that Ms Moore was advised that Mrs Kelly's sacrum and both heels were red and that gel socks had been applied. I do not accept that, as stated in your report, "it is fair to conclude that, on the balance of probabilities, the complainant was not advised by the Clinical Nurse Manager that her mother had developed red pressure areas before she took her home from St. Mary's".

 Your report appears to draw conclusions from the fact that the Clinical Nurse Manager did not mention that another staff member was present when she spoke with Mrs Moore prior to her taking her mother home. However, your staff did not enquire from the Clinical Nurse Manager whether or not there was a witness to the discussions. The report all but dismisses the evidence provided by the staff nurse who was a witness to these discussions. Doubts are cast on her evidence on the basis that this nurse stated that she had given Mrs Kelly a bed bath prior to her going home and a different nurse signed the daily care flow chart. However, a bed bath is given by two nurses or a nurse and care assistant and only one staff member signs the chart. It is difficult to find the justification for accepting Mrs Moore and her son's recollection and dismissing the evidence of the Clinical Nurse Manager and the staff nurse. Throughout the report greater weight appears to be given to information provided by Mrs Moore than the reports and recollections of staff who were present on the ward.

Nursing staff are confident that, whilst Mrs Kelly had red areas on her sacrum and heels when leaving St. Mary's Care Centre, there were no blisters present. The Director of Nursing took notes during the telephone conversation which took place at 3.30 p.m. on Thursday, 15th with Mrs Moore following her mother's return home and Mrs Moore made no reference to blisters at that time. No reference was made to the presence of blisters until 8.55 p.m. that night. It should be noted that blisters can develop very rapidly in a person of Mrs Kelly's age and state of health.

Your report states that "I think it is fair to conclude that the nature of the care the complainant's mother received over the previous three days must have been a contributory factor in the development of the blisters". This statement is then followed by a reference to correspondence from the General Manager to Mrs Moore in which she acknowledged the fact that the care provided to Mrs Kelly fell short of the standards of excellence which management and staff continually strive to achieve. The purpose of taking this reference out of context and linking it with the investigator's own opinion would appear to be an attempt to give credence to that conclusion, when, in actual fact, the General Manager was referring to the breakdown in communication which led to the difficulties in having Mrs Kelly's swallowing difficulties optimally managed.

With regard to medication given to Mrs Kelly during her stay at St. Mary's Care Centre, you state in your report "I feel that it is reasonable to conclude that Mrs Kelly could not have received the required dosages Mrs Kelly's medication was signed for and recorded as being administered and to conclude otherwise is to suggest that the nursing staff falsified records. I believe that this is unfair to the staff involved who have co-operated fully with the HSE's own internal investigation of the matter and the Ombudsman's subsequent formal investigation. Furthermore, Mrs Moore took her mother home against medical advice when the medical officer in St. Mary's advised that she be transferred to the Midland Regional Hospital at Mullingar. You take issue with the fact that Mrs Moore was not provided with medication for her mother on discharge and support your view with reference to discussions with colleagues in the Department of Health. Following discussions with relevant staff and checking of ambulance records, I can confirm that Mrs Moore had ample time to contact her GP and collect medication from a pharmacy for her mother following her removal from St. Mary's. Furthermore, as Mrs Moore chose to take her mother out of St. Mary's and refused to follow medical advice, the medical officer had no clinical responsibility in the matter and it would have been entirely wrong for him to issue Mrs Kelly with medication. I feel that the Ombudsman's office would have been well advised to engage appropriate clinical expertise in this investigation rather than relying upon informal discussions with staff from Department of Health and information downloaded from Irishhealth.com, which was referred to in previous correspondence.

On the matter of pursuing her complaint, Mrs Moore was aware of the process involved in carrying out the desktop review. All staff involved in the care of Mrs Kelly were interviewed as part of the review. The report was based on the interview notes as well as the medical and nursing records. Whilst this process did take longer than was originally anticipated, it is not clear from the report that communication was ongoing with Mrs Moore and that she was kept fully informed of the progress of the review. Whilst she may not have been in direct contact with the General Manager, she was in communication with the Community Services Manager and his staff, who were dealing with the matter on the General Manager's behalf. This has not been given sufficient mention in the report despite the fact that, upon receipt of the draft extract issued previously, the General Manager made a submission to the Office of the Ombudsman to this effect.

When referring to the desktop review, a large number of the recommendations of the report are not included in this draft final report. An action plan was forwarded to the investigator from the Ombudsman's Office on 21st November 2006 which details a number of other recommendations not included in the report. I would appreciate if this information could be included in the final report.

With regard to the meeting that was due to take place on 29th June 2006, the report states that Mrs Moore felt 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". The Clinical Nurse Manager was on duty for 8 hours on Wednesday, 14th December and from 8 a.m. on Thursday 15th December. In effect she was on duty for approximately 11 hours out of the 72 hours that Mrs Kelly was on the ward.  Mrs Moore was advised that the Clinical Nurse Manager would not attend the meeting upon her arrival at St. Mary's. Whilst I accept that she had an expectation that the Clinical Nurse Manager would be present at the meeting, she was assured that all of her questions and concerns would be recorded and she would be given a written response to all concerns that could not be addressed during the course of the meeting. She refused this option and was very angry and aggressive. {...} Whilst your report acknowledges that the Director of Nursing could have dealt with Mrs Moore's concerns, it still goes on to conclude that the presence of the Clinical Nurse Manager at the meeting would have been beneficial. I do not accept that this would have been the case and I believe that had the meeting gone ahead and had the Clinical Nurse Manager felt compelled to withdraw during the course of the meeting, this would, no doubt, have further damaged the communication process.

I wish to express my own dissatisfaction and that of the staff at St. Mary's with the time-frame in which this process is taking place. The Office of the Ombudsman carried out interviews with staff in St. Mary's at the end of August 2006 and staff were advised at the time that a report would issue in approximately six weeks. The issues raised by Mrs Moore were dealt with during the course of these interviews and staff were of the understanding that the Ombudsman's Office was working in the capacity of facilitator. It later transpired that Mrs Moore was given feedback from these interviews. However, staff were not given a copy of this correspondence prior to its issue, despite having been given previous assurances that this would be the case. The Community Services Manager was advised in April 2007 that the Ombudsman had decided to undertake a formal investigation. Extracts of the draft report were not issued to relevant staff until October 2007, six months later. Responses by staff were returned to your office by the end of November 2007. However, the final draft report was not issued to me until 4th March 2008. As you will appreciate, staff have found this entire process very stressful and the fact that it has taken such a long time to complete has added to this anxiety and stress. I wish to state that the staff of St. Mary's Care Centre fully co-operated with the Ombudsman's office during the course of this investigation and made detailed submissions in response to the initial draft extracts. I am disappointed that these submissions were not given due consideration and weight in the report and, at all stages throughout the report, conclusions are drawn which appear to favour the complainant's version of events.

I trust my comments and observations will be considered prior to the publication of the final report. I also wish to request that all formal submissions issued by HSE staff to the Ombudsman's Office in response to the draft extracts and the draft final report, be included in the appendices of the final report.

Yours sincerely,

 

Joseph Ruane

Local Health Manager

Longford/Westmeath

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