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December 2010 - Care and treatment of a patient and his family

A Report on an Investigation by the Ombudsman in relation to a complaint about the care and treatment of a patient and his family at Mid-Western Regional Hospital, Dooradoyle, Limerick

Summary of Report

  Summary of Report (pdf, 20 kb)

Text Summary of the Investigation Report

Full Report

Appendices - 2 and 5 referred to in this report, are only available as pdf documents (see below).  If you have difficulty accessing any of the pdf documents and require an alternative format please contact our Access Officer

  Downloadable version of the full report (pdf, 273 kb)

Contents

Chapter 1 - Introduction

1 - Introduction and the role of the Ombudsman and clinical decisions

Chapter 2 - Investigation

2.1 - Statement of Complaint

2.2 - Interview with Complainant

2.3 - Response from Health Service Executive

2.4 - INTERVIEWS

2.4.1 - Interviews with nursing staff

2.4.2 - Interview with Dr Red, Consultant Physician

2.4.3 - Interview with Dr Greene, Specialist Registrar on-call

2.4.4 - Interview with Mr Glynn, Senior Anatomical Pathology Technician

2.4.5 - Interview with Ms Merrigan, Hospital Business Manager

2.4.6 -Interview with Dr Finnegan, Medical Intern on-call

2.4.7 - Interview with Dr Murnane, Registrar to Dr Red, Consultant Physician

2.4.8 - Interview with Ms. Stokes, Nurse Care Assistant

Chapter 3 - Analysis

3.1 - Delay in performing CT Scan

3.2 - Observation of the patient's fall

3.3 - Falls Assessment

3.4 - Waiting four hours to advise the family of the patient's fall

3.5 - Time of the fall

3.6 - Skull X-ray

3.7 - Bed Side Bell

3.8 - Mortuary Register

3.9 - Failure to carry out a post mortem

3.10 - Treatment of the remains and family on the ward

3.11 - Visit from Tea Lady

3.12 - Possibility of Surgery

3.13 - Delay in signing the Medical Certificate of the Cause of Death

3.14 - Delay in Notifying the Coroner of the patient's death

3.15 - Record keeping

3.16 - The family’s wishes with regard to an exhumation and post mortem

Chapter 4 - Findings

Introduction

4.1 - Post mortem and notification of Coroner

4.2 - Treatment of the remains and family on the ward

4.3 - The patient’s fall

4.4 - Delay by the Hospital in signing the Medical Certificate of the Cause of Death

4.5 - Record Keeping

4.6 - Advice from Consultant regarding surgery

4.7 - CT scan

4.8 - Skull X-ray

4.9 - Patient's Pyjamas

Chapter 5 - HSE's Response to the Draft Investigation Report

5 - HSE's Response to the Draft Investigation Report

Chapter 6 - Recommendations

6 - Recommendations

Appendices

Appendix 1 - HSE's Response to Recommendations of Final Report and Action Plan

  Appendix 2 - The HSE’s Initial Review Report (Dec 2005) (pdf, 274 kb)

Appendix 3 - A Post mortem

Appendix 4 - The Coroner

  Appendix 5 - Sample Copy of the Certificate of the Cause of Death Form (pdf, 69 kb)

Appendix 6 - Registering a death

Appendix 7 - The Glasgow Coma Scale

Appendix 8 - Neurological Observations Chart