I recommend that
Mayo General Hospital and the Respiratory Function Laboratory in Merlin Park Hospital, Galway, complete a comprehensive review of the system for requesting and reporting all respiratory tests (including Lung Function Tests). This should incorporate a risk assessment of current procedures with a view to establishing a process which would ensure that :-
Tests are requested in the most efficient manner possible; contact details of the referring doctor are included, to allow urgent contact by the laboratory to be made if required; and there is a facility for the referrer to indicate the priority / urgency of any given test.
All results are reported as efficiently as possible, and in particular, abnormal results are identified and communicated to the referring consultant and/ or medical team, in a manner that is appropriate to their significance.
The consultant and / or medical team demonstrate that they have received the results and acted on them as appropriate.
Test results (given the concerns I have expressed in paragraphs 4.4 and 5.6 of this report) which are requested and/ or appropriate for the GP's attention, are provided in their entirety to the GP, in a timely manner. Specialist clinical opinion attached to the results and provided to describe the test result, should always accompany the results themselves.
The feasibility of using communication technology is explored to achieve all of the above, but in particular, the instantaneous delivery of results to those directly involved in the care of the patient.
There is regular audit of the system for requesting and reporting tests.
Mayo General Hospital complete a comprehensive assessment and review of the arrangements by all clinical staff in relation to how post, which may contain patient related information, is actively managed.
Procedures should be in place to ensure that post, which may contain critical patient related information, is date stamped on receipt, opened daily and acted upon as appropriate.
In light of the conflicting presentations at paragraph 5.3 of this report about arrangements for the receipt on incoming patient-related post, Management at Mayo General Hospital should, in consultation with Dr Smith, immediately take appropriate measures to ensure that there is absolute clarity over the approved arrangements for receiving, disseminating and acting upon such post.
When duties and responsibilities of staff employed privately by consultants include the completion of work relating to public patients, these practices should be reviewed, to ensure clarity about the role of such staff across the hospital system and appropriate governance relating to confidentiality of public patient records etc.
Mayo General Hospital review its data capture techniques and procedures to ensure that all patient deaths are entered to the Hospital's Information System. These should include:- deaths which occur in the Hospital, deaths which occur in transit to the Hospital via ambulance and all remains which are presented to the Hospital.
In conjunction with 6.3 above, to avoid unnecessary distress to grieving family members, Mayo General Hospital should review its procedures and put measures in place to ensure that
- no appointments are scheduled and
- no appointment cards are issued in respect of deceased patients.
In conjunction with 6.3 above, the HSE should continue to review its procedures and put measures in place for renewing Medical Cards, to ensure that no renewal notifications are issued in respect of deceased persons.
The HSE should
- review the current complaint handling procedures in Mayo General Hospital to ensure that they are consistent with the Health Act 2004 (Complaints) Regulations, 2006 (S.I. No. 652 of 2006), particularly Article 8 which stipulates, among other issues, the timeframe within which a complaint should be investigated and completed.
- ensure that Mayo General Hospital makes freely available information on making a complaint and the complaint handling process. This should include publication of its complaint examination procedures on its website.
- monitor annually the compliance of Mayo General Hospital's complaint examination procedures with the governing regulations and the HSE's own complaint handling performance indicators.
I also recommend that
The findings of this investigation be drawn to the attention of all staff involved with the care of the late Mrs Brown at Mayo General Hospital and Merlin Park Hospital, Galway, in the period November to December 2004.
A member (or members) of the senior management team in Mayo General Hospital visit the Brown family to apologise, once again, for the shortcomings identified in this report and to explain what action is being taken on foot of the findings and recommendations contained in the report.
The HSE ensures that the National Director of Clinical Care and all public and voluntary hospitals be made aware of the clinical governance and corporate governance issues in this investigation and the recommendations for systemic improvements.
The HSE makes a "Time and Trouble" ex-gratia payment, on a without prejudice basis, in the sum of €5,000, to the Brown family, in recognition of the effort expended by them in the pursuit of their complaint and the unacceptable delay in the examination of their complaint.
Emily O'Reilly
Ombudsman