Appendices

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

Appendix 2 - The HSE’s Initial Review Report (Dec 2005)

Appendix 3 - A Post mortem

Appendix 4 - The Coroner

Appendix 5 - Sample Copy of the Certificate of the Cause of Death Form

Appendix 6 - Registering a death

Appendix 7 - The Glasgow Coma Scale

Appendix 8 - Neurological Observations Chart

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

19 April 2010

Mr Pat Whelan,

Director General,
Office of the Ombudsman,
18 Lower Lesson Street,
Dublin 2

Re; Draft Report and Findings of Ombudsman Ms A V the Mid Western Regional Hospital, Limerick

Dear Mr Whelan,

I refer to your letter of 19 March 2010 to Professor Brendan Drumm, Chief Executive Officer, HSE, concerning the Ombudsman's investigation of the complaint received from Ms A, which has been forwarded to me for attention.

The management of the Mid Western Regional Hospital, Limerick acknowledges receipt of your draft report in relation to the above investigation.

Hospital management accepts that there were a number of administrative failings at ward management and system level in the care and treatment of Mr A (RIP) for which the hospital apologises unreservedly to the family.

In the interim period a number of steps have been taken to address the weaknesses which contributed to such failures with regard to;

• Healthcare record keeping and communication
• Falls management
• Post Mortem Practice

A continuous quality improvement cycle underpins our approach to address these issues which includes explicit standards, audit and clarity on roles and responsibility.

4.1 Post Mortem and notification of Coroner

The management of the Mid Western Regional Hospital acknowledges and apologises for the failure of a number of staff to adhere to the hospital policy and advise the coroner of the death of Mr A in a timely fashion, The delay in the notification to the coroner was not intentional and the subsequent adverse affect on the family is deeply regretted.

The following measures have been introduced to avoid this breach of hospital policy in the future.

1. Inclusion of the Hospital Post Mortem Policy as part of the Non Consultant Hospital Doctor Training Day.
2. Inclusion of the Hospital Post Mortem Policy as part of the Non Consultant Hospital Doctor Induction Manual.

A death notification checklist and process is also being finalised. This checklist includes;

1. Timely reporting of deaths to the Coroner.
2. Instruction to ensure that the outcomes of discussions with the coroner are appropriately recorded.

Arrangements are also being made by the HSE at National level to ensure that induction training generally for non consultant hospital doctors includes protocols for the appropriate notification of patient deaths to the coroner.

4.2 Treatment of the remains and family on the ward

Hospital management regrets that official records to ascertain the length of that Mr A (RIP) remained on the ward after his family had left were not available to the investigator from the office of the Ombudsman. In order to address this deficit a checklist for staff is being finalised.

The requirement to afford the highest level of dignity to patients nearing the end of life is fully recognised and in this regard the hospital participated in a baseline "National Audit of End of Life Care in Hospitals (2008-9)" which was coordinated by the Irish Hospice Foundation. The findings of this audit are due to be published by the Irish Hospice Foundation at the end of April 2010.

The next phase of this programme involves the development of an action plan based on the findings of the "National Audit of End of Life Care in Hospitals (2008-9)" and the "Quality Standards for End of Life Care in Hospitals". Hospital management are committed to the implementation of the action plan as soon as it is developed.

Where possible, all patients nearing end of life are afforded privacy in a single room. However, on occasion, clinical and infection control pressures impinge on the availability of single rooms.

Hospital management wishes to apologise for the breakdown in the communication between the ward staff and the family on this occasion.

Arrangements have been put in place to alert all staff when a patient has died, advising that they are not to enter the area without consulting the nurse in charge.

4.3 The patient's fall

i) The Bed Side Bell

Hospital management acknowledges your findings in regard to the bed side call bell. It was never the intention to either misconstrue the information provided by the Ward Manager or mislead the Ombudsman in relation to the presence of the bed side bell. Hospital management regrets any confusion caused by this inadvertent error in communication in relation to this matter to your investigator.

It is unfortunate that the investigator did not revert to the hospital to seek clarification with regard to the call bell issue following the Ward Manager's response.

It is noted that your investigator reverted to the hospital for subsequent clarification regarding the allegation by one of the nursing staff that the time on the incident form had been altered.

Since 2005, the nursing care plan and assessment has been reviewed and a more detailed assessment / care plan has been introduced. Training has also been provided to staff as part of the 'roll out' of the introduction of the new documentation. The care plan is completed at the time of admission and part of this process incorporates issues of safe environment and mobilisation.

A further requirement of this assessment requires verification that,

1. The call bell is working,
2. Within reach,
3. The patient understands its operation.

This assessment addresses the issue of both the presence and functionality of' the call bell. This is documented in the environmental assessment section of the Nursing Admission and Assessment Form.

Hospital management acknowledge and apologise for the incomplete maintenance records for the period concerned. This deficit in relation to the presence and functionality of the call bell is now addressed, as outlined above, in the environmental assessment at the time of admission.

ii) Observation of the patient's fall

Hospital management accepts and notes your findings in relation to the patient's fall.

iii) Bed Side Rails

Hospital management accepts that the documentation was absent in regard to bed side railings and the fact that a falls assessment was not completed. This now comprises part of the patient assessment on admission and is reviewed, updated, documented throughout the patient stay as necessary.

Since 2008 a nursing guideline for the use of bed rails has also been introduced and implemented.

iv)Time of fall

Hospital management accepts and acknowledges your findings in relation to the documentation around the time of the fall and the unauthorised corrections are noted. Accurate and contemporaneous record keeping is central to the provision of clinical care and in this regard, training has been reinforced on an ongoing basis to all nursing staff. An audit of nursing documentation was completed in 2009.

A guideline on document and record writing has also been implemented

v) Notifying of the family of the fall several hours later.

Hospital Management notes the Ombudsman's acknowledgement of the appropriateness of the actions of the hospital staff in relation to notification to the family of the time of the fall having regard to the time of the first "observations", as recorded on the patient's neurological observation chart.

4.4 Delay by the Hospital in signing the Medical Certificate of the cause of Death

Hospital management wish to inform you that the patient administration system (PAS) was updated at 17.16 hrs on the day of Mr A's death (RIP).

Unfortunately, it cannot be verified or established if Ms A was given her father's chart by a staff member on the ward and asked to bring it to the Medical Records Department as this is the first occasion this matter has been raised. A chart tracking system has since been introduced to assist in ensuring that the Medical Records Department staff members are aware of the location of medical charts.

It is unacceptable that there was a two week delay in transferring the patient's medical record to the consultant secretary and this should not have arisen. Hospital management apologises to the family for any adverse impact arising from this delay.

4.5 Record Keeping

Hospital management accepts and acknowledges that there were unacceptable deficits in relation to record management practices despite ongoing training for nursing and healthcare staff. Hospital management regrets any impact these deficits may have had on your investigation.

The deficits are being addressed as follows:

1. The hospital completed a self assessment in 2009 with regard to the National Hospitals Office Code of Practices for Standards in Healthcare A quality improvement plan has been developed and the hospital healthcare records committee is overseeing implementation of same.
2. A nursing documentation audit was undertaken in 2009.
3. A document and record writing guideline has been implemented.

4.6 Advice from Consultant regarding surgery

Hospital management notes that you are unable to reconcile the two versions of the events and accept your conclusion with.regard to the above.

4.7 CT Scan

Hospital management notes your finding and accepts your conclusion with regard to the provision of a CT scan given Mr A's (RIP) presenting condition.

4.8 Skull X-Ray

Hospital management notes your findings with regard to this matter.

4.9 Patient's Pyjamas

Hospital management accepts your findings in relation to the poor communication in relation to the patient's soiled pyjamas. The hospital is currently updating a patient information leaflet which will include information on the management of in-patient personal laundry. This updated leaflet will be available in May, 2010.

Hospital management hope the above observations are of assistance to you in completing your investigation. However, if you require any further assistance please do not hesitate to contact me.

Yours sincerely,

Laverne McGuinness,
National Director,
Integrated Services Directorate,
Performance & Financial Management

Recommendation Action Plan

Appendix 2 - The HSE’s Initial Review Report (Dec 2005)

Appendix 3 - A Post mortem

In certain situations when someone dies in Ireland, it may be necessary to carry out a post mortem examination (also called an autopsy) of the deceased's body. A post mortem examination is a medical examination of a dead body to determine the exact cause of death. In the case of a violent death, the post mortem may be necessary as part of a criminal investigation. Post mortems in Ireland are carried out by a specific type of physician called a 'pathologist'.

The family or next of kin will normally be asked for their permission before a post mortem is carried out. However, where a Coroner has ordered a post mortem examination, the permission of the next of kin is not necessary.

Following the post mortem examination, the body will normally be released to the spouse or next-or-kin immediately after the examination has been completed

Although the need for a post mortem will not usually delay the funeral, the results may not be available until three to eight weeks later. In certain circumstances, it may be several weeks before the post mortem report is received from the pathologist.

A person can discuss the results with the deceased's doctor once the results are available, and one can then proceed with registering the death in the usual way. One cannot register the death until the post mortem results are received by the Coroner's Office. Prior to inquest (or whilst awaiting the post mortem report) the Coroner will provide on request an Interim Certificate of the Fact of Death.

(Reference source: www.citizensinformation.ie)

Appendix 4 - The Coroner

A Coroner in Ireland is an independent official with legal responsibility for the investigation of sudden and unexplained deaths. The role of the Coroner is to enquire into the circumstances of sudden, unexplained, violent and unnatural deaths. This may require a post mortem examination, sometimes followed by an inquest. The post mortem is carried out by a Pathologist, who acts as the Coroner's agent for this purpose. The Coroner's inquiry initially is concerned with establishing whether or not death was due to natural causes.

The Coroner essentially establishes the "who, when, where and how" of unexplained death. A Coroner is not permitted to consider civil or criminal liability; he or she must simply establish the facts. If a death is due to unnatural causes, then an inquest must be held by law. The principal legislation that established the role and responsibilities of Coroners in Ireland is the Coroners Act 1962.

A Coroner will not be involved in cases where a person died from a natural illness or disease for which the deceased was being treated by a doctor within one month prior to death. In this case, the doctor will issue the medical certificate of the cause of death. The death can then be registered and a death certificate can be obtained.

In cases of sudden, unnatural or violent death, there is a legal responsibility on the doctor, registrar of deaths, funeral undertaker, householder and every person in charge of any institution or premises in which the deceased person was residing at the time of his/her death, to report such a death to the Coroner. The death may be reported to a member of An Garda Síochána, not below the rank of sergeant, who will notify the Coroner. However at common law, any person may notify the Coroner of the circumstances of a particular death.

In situations where a medical certificate of the cause of death is not available, the Coroner will arrange for a post mortem examination of the body. If the post mortem examination shows that death was due to natural causes, and there is no need for an inquest, a Coroner's Certificate will be issued to the Registrar of Births and Deaths who will then register the death and issue the death certificate.

If death is due to unnatural causes, the Coroner is obliged to hold an inquest. The death will be registered by means of a Coroner's Certificate when the inquest is concluded (or adjourned in some cases).

Prior to the inquest (or whilst awaiting the post mortem report), the Coroner's office will provide an Interim Certificate of the Fact of Death, which may be acceptable to banks, insurance companies and other institutions.

Deaths reportable to the coroner include the following:

(a) Deaths occurring at home or other place of residence:

• where the deceased was not attended by a doctor during the last illness;
• where the deceased was not seen and treated by a doctor within one month prior to date of death;
• where death was sudden or unexpected;
• where death may have resulted from an accident, suicide or homicide;
• where the cause of death is unknown or uncertain;
• where concerns are expressed by any person in relation to a death.

(b) Deaths occurring in hospital:

• where a patient dies before a diagnosis is made and the general practitioner is also unable to certify the cause;
• when death occurred whilst a patient was undergoing an operation or under anaesthesia;
• where death occurred during or as a result of any procedure;
• where any question of negligence or misadventure arises in relation to the treatment of the deceased;
• where death resulted from an industrial disease;
• where death was due to neglect or lack of care (including self-neglect);
• where death occurred in a Mental Hospital.
• where death may have resulted from an accident, suicide or homicide.

(Source: www.citizensinformation.ie)

Appendix 5 - Sample Copy of the Certificate of the Cause of Death Form

Appendix 6 - Registering a death

It is a legal requirement in Ireland that every death that takes place in the State must be recorded and registered. Records of deaths in Ireland are held in the General Register Office, which is the central civil repository for records relating to Births, Marriages and Deaths in the Republic of Ireland.

A death can be registered with any Registrar, irrespective of where it occurs. Deaths must be registered as soon as possible after the death and no later than three months. It is usually registered by the next of kin.

A doctor must be satisfied about the cause of death before he/she can certify it. If he/she didn't see the deceased at least 28 days before the death occurred, or if he/she isn't satisfied about the cause of death, he/she must inform a Coroner who will decide if a post mortem is necessary. If the deceased died as the result of an accident, or in violent or unexplained circumstances the coroner must be informed. There may be a delay in registering a death where a post mortem is carried out. The death is automatically registered where an inquest or post mortem is held at the request of the Coroner. The Coroner issues a certificate to the Registrar containing all the details to be registered. Deaths should be registered as soon as possible and no later than 3 months from the date of the death.

A death is registered by the Registrar of Births and Deaths for the registration district in which death occurs. A relative or other eligible person must obtain a Medical Certificate of the Cause of Death from the medical practitioner who attended the deceased during the last illness. A death is registered when a qualified informant (often a spouse or next-of-kin) attends at the office of the Registrar of Births and Deaths and provides the following information:

• Date and place of death
• Full name and surname of deceased
• Marital status of deceased (married, bachelor, spinster, widowed or divorced)
• Sex of deceased
• Age or date of birth of deceased
• Occupation of deceased

The person registering the death must also produce a Medical Certificate of the Cause of Death signed by a doctor who treated the deceased within one month prior to death. A death is registered in the district in which death occurred and not where the deceased was resident.

Where a death is reported to the coroner and is the subject of a post mortem examination or inquest, registration will be effected by means of a Coroner's Certificate after the post mortem or inquest. The Death Certificate will then be available from the District Registrar's office.

(Source: www.citizensinformation.ie)

Appendix 7 - The Glasgow Coma Scale

The Glasgow Coma Scale (GCS) is a neurological scale which aims to give a reliable, objective way of recording the conscious state of a person. A patient is assessed against the criteria of the scale, and the resulting points give a patient a score between 3 (indicating deep unconsciousness) and 15.

Generally, brain injury is classified as

Severe - with scores of 3-8 (which is the generally accepted definition of a coma)

Moderate - with scores of 9 - 12 and

Minor - with scores greater than 13.

The total score is the sum of the scores in three categories.

(Reference source: www.unc.edu/~rowlett/units/scales/glasgow.htm)

Appendix 8 - Neurological Observations Chart

Neurological observations include assessment of conscious level, vital signs, pupil size and reaction, motor response, and verbal response. These observations are taken at regular intervals and documented / mapped on a chart.