2.1 - Statement of Complaint
2.2 - Interview with Complainant
2.3 - Response from Health Service Executive
2.1 - Statement of Complaint
My Office initially carried out a preliminary examination of the complaint. I was not satisfied that the HSE’s review of the complaint (Appendix 2) was sufficiently comprehensive or detailed, and due to the serious issues presenting, I decided to commence an Investigation into the complaint in April 2007, under Section 4(2) of the Ombudsman Act 1980.
The investigation involved examination of medical, nursing, risk management, mortuary and ward records; interviews with hospital staff; liaison with the Coroner’s office; and review of Hospital policies.
To commence the investigation, I wrote to the HSE on 20 April, 2007, with a Statement of Complaint set out as follows:
Background
Mr Brown was a 61 year old man who was admitted to the Mid-Western Regional Hospital, Limerick in October 2005. He was diagnosed with a stroke/ cerebellar haemorrhage. Early in November 2005, Mr Brown was moved to a high dependency medical ward. (This was later corrected by the HSE. Mr Brown was moved to a Medical Ward.) The next day he was visited by members of his family who were pleased with his progress. Later that week, the family received a phone call early in the morning from the hospital advising that Mr Brown had fallen out of bed at 2.15am.
He suffered a broken tooth, an 8cm (3in.) laceration to the back of his head and cuts to his tongue. He subsequently entered into a deep unconscious state and died approximately 52 hours after his fall. Shortly after his death, the family was asked to leave the ward as hospital staff wished to move his body to the Mortuary. However, once the family left the hospital, Mr Brown's body remained in the hospital bed on the busy ward for a further 6 hours before he was moved to the Mortuary.
Statement of Complaint
The complaint is that
- There was a delay in performing a CT scan on the patient when he was first admitted to the hospital;
- The patient's fall, or the moments leading up to it, was not observed by any of the five nursing staff on duty;
- The patient suffered a serious fall in a high dependency ward, yet there was a delay of 4 hours in advising the family of the fall;
- There were three different recordings of the time of the fall, one at 1.30 am, one at 2.00am and one at 2.15am; later it was discovered that there was a fourth recording of the fall, at 2.20am.
- The Medical Notes suggested that a skull X-ray was to be performed on the patient following his fall. However, this X-ray was not conducted;
- The family noticed that there was no call bell on their father's bed when they visited him on the morning of his fall;
- After Mr Brown had died and while his body was lying in bed, on the busy ward, one of the tea ladies who was on her routine rounds, drew back the screening curtains and asked members of the family whether Mr Brown would be having breakfast that morning;
- Some time after Mr Brown had died, the family were asked to leave the ward on the pretext that the hospital wanted to remove his body to the Mortuary. However, six hours later, his body was still lying in the bed on the busy ward and had not been moved;
- There was a failure to advise the family of its rights to have a post mortem conducted;
- There was a failure to carry out a post mortem in line with hospital policy following the death of the patient;
- There was a failure to consider Mr Brown's death at a conference; After Mr Brown had died, the family was advised by the consultant that their father could have had surgery;
- There was a delay by the Hospital in signing the Medical Certificate of the Cause of Death;
- There was a delay of 2 weeks in notifying the Coroner of the patient's death.
2.2 - Interview with Complainant
As part of the complaint examination process, one of my Investigators met with the complainant. The complainant explained that, on the afternoon before her father's fall, Mr Brown was sitting out in his chair and chatting away to his family. He was alert, aware of everyone present and was eating healthily. He was able to stand up, but he was a little unsteady on his feet. He was complaining of a headache.
The next day, the family received a phone call at about 5.45am from the hospital advising them that their father had had a fall. They were advised to come to the hospital.
When they approached Mr Brown's bed, he was awake but sweating very heavily and breathing very fast. He opened his eyes and looked around. Within three minutes however, he started seizing. Dr. Greene, the Specialist Registrar in Medicine who was on-call that night, advised the family on that morning that he had probably had a secondary bleed and that he was most likely dying.
The complainant told my Office that the family was told that their father had climbed out over the end of the bed. However, the family was not advised about the extent of the injuries their father had sustained following his fall. They said that there was no mention of the 8cm laceration to the back of his head, his broken tooth or the cut to his tongue.
The family spent the next 48 hours with their father and were with him when he died. When he died, the curtain was pulled around his bed and the usual ward activities continued.
The complainant told me that, at about 10am, less than two hours after he died, the family was asked by a staff member to vacate the ward. They were told that staff needed to get organised and to arrange for Mr Brown to be removed to the Mortuary. Later, the complainant told me that she was advised by the Funeral Home Directors that Mr Brown's body was left in his bed for over six hours after the family had left the ward. The complainant said that if the family had known their father was lying in the hospital bed alone in a busy ward, they would have arranged for someone to sit with him.
Some time after Mr Brown died, the family told me that the Tea Lady popped her head around the curtain and asked "Is there breakfast here?" The family looked at her in dismay. On seeing the response, the Tea Lady simply said "all right" and she carried on with her duties. The family said that they have no complaints about the Tea Lady, but they felt that Nursing staff failed in their duty to advise callers and other staff members about a death on the ward.
The complainant told my Office that her father's pyjamas were covered in urine from top to bottom when her sister found them in her father's locker in a plastic bag after he had died. The wet pyjamas had been in the locker for more than three days at this stage.
The complainant told me that she wanted answers to her questions. She felt that her father sustained a helpless fall from his bed and she wanted clarification as to whether it was the fall, rather than the medical condition for which he was admitted, which led to his death.
She was not convinced that her father died from the condition for which he was admitted to the hospital.
Given there was no post mortem (see Appendix 3), the family had a number of unanswered questions. They wanted my Office to pursue their complaint and attempt to establish what exactly happened. They also expressed their belief that an exhumation and post mortem of Mr Brown's remains would be the only definitive way of establishing his cause of death. The family told me that they had contacted the Gardaí after Mr Brown’s death and that the Gardaí had taken statements from Hospital staff and contacted the Coroner (see Appendix 4). Later, the complainant contacted the Coroner herself. The Coroner told her that he was informed of the death 2 or 3 weeks after the patient's death. An inquest was held in April 2006, where an open verdict was returned.
About 2 or 3 weeks after Mr Brown died, the complainant needed her father's Death Certificate (see Appendix 5 (pdf 69kb) and Appendix 6). She went into the hospital and called to the Medical Records Department. She was told that there was no record of her father's death on the computer. She was advised to go to the ward. She went to the ward and saw that her father's file was still on the desk at the Nurses' Station.
2.3 - Response from Health Service Executive
The following response was received from the HSE with regard to each point raised in my statement of complaint to them.
2.3.1 - Delay in performing a CT scan on the patient when he was first admitted to the hospital
The HSE said that, when Mr Brown first presented to the Emergency Department, his clinical condition did not indicate that he required an emergency CT scan of his brain. It was decided to admit, monitor and treat him in the Coronary Care Unit on the night of his admission. The HSE said that, further to a consultation with the Consultant Radiologist on-call, a decision was made to wait until the following morning to do a scan, unless the patient's condition deteriorated during the night.
The hospital reported that the medical notes also contain written instructions in regard to monitoring his neurological observations. These notes state that if there was any deterioration in his condition, the patient was to be reviewed by the medical team on call and his treatment altered as necessary. The HSE pointed out that Mr Brown was stable overnight, with the exception of an ischemic change on his electrocardiograph at 7am the following morning.
Dr Red, the Consultant Physician in charge of Mr Brown's care, advised that there was no clinical indication to necessitate an emergency CT scan on the night he was first admitted.
2.3.2 - The patient's fall, or the moments leading up to it, was not observed by any of the five nursing staff on duty.
The HSE said that Mr Brown was a patient in the main ward of Medical Ward X. This is an acute male medical ward with thirty three beds, fifteen of which are in the main ward. It clarified that the ward is not high dependency and is staffed by four staff nurses on night duty.
It said that, for the purposes of care delivery, two staff nurses are allocated to the main ward and two staff nurse are allocated to care for the patients in private and semi private rooms on the corridor. In addition to the usual staff complement, there was a student nurse on placement on the night shift.
The HSE said that Mr Brown was nursed in a particular bed space to ensure he was observed and monitored closely. The floor lights were on to facilitate patients who needed to get out of bed during the night and to provide a light source for observational purposes.
The HSE acknowledged that Mr Brown's fall was not observed as it occurred. However the noise of the patient falling was heard by Staff Nurses Fox and Howe who were both writing reports at the Nurses' Station, which is in close proximity to the ward. Staff Nurse Philpot and Staff Nurse Waddell, Agency Nurse, who were caring for patients in the ward, were both on a lunch break away from the ward. On their return to the ward, they assisted the two nurses who were attending to Mr Brown to lift him back to bed.
2.3.3 - Advising the family four hours after the fall
The HSE explained that, after Mr Brown was found on the floor beside his bed, his immediate needs were attended to, his vital signs (i.e. blood pressure, temperature, pulse and respiration) were measured and the Glasgow Coma Scale (Appendix 7) completed (These were done to monitor his medical and neurological condition). The doctor was also contacted and attended Mr Brown. His Glasgow Coma Scale measurement was satisfactory at 13 out of a possible 15.
It was checked regularly and remained stable until 5.20am when it measured 8 out of 15, indicating a marked deterioration in his level of consciousness. Further to this deterioration, a decision was taken to contact the family.
The Clinical Nurse Manager II on the ward advised that, unless a patient's condition changed significantly or he became gravely ill, it would be unusual to disturb the family in the middle of the night. However, she said that each situation is assessed and, if the situation necessitates ringing the family, then this action is taken.
2.3.4 - Different recordings of the time of the fall.
The HSE acknowledged that there are three different recordings of the time of the fall. The HSE discussed this issue with the staff nurses and it advised my Office that the time recorded is approximate. This is because attending to the patient's immediate needs is the nursing staff's first priority. It explained that every effort is made to ensure that the recording of details is as close as possible to the time of the event.
The HSE made the point that the Incident Report Form was completed by Nurses Howe and Fox who heard the noise and went to Mr Brown's aid, and the Nursing note was recorded by Nurse Philpot who was caring for patients in the main ward that night with Nurse Waddell.
2.3.5 - Skull X-ray not conducted
The HSE confirmed that Dr Red, Consultant Physician, cancelled the skull X-ray following a review of the patient, the morning after his fall.
2.3.6 - Call bell on bed
The HSE said there was a call bell at Mr Brown's bed at all times during his illness. It further stated that staff members ensure that the call bell is easily accessible to all patients and that it is placed depending on individual patient requirements. It also explained that there is a system in place in the ward to check on all fixtures (oxygen, suction and call bell) at patients' beds at regular intervals.
2.3.7 - Failure to advise the family of its rights to have a post mortem conducted
The HSE admitted that the family was not advised of their right to have a post mortem conducted.
2.3.8 - Failure to carry out a post mortem
The HSE admitted that there was a failure to carry out a post mortem on the patient and the hospital acknowledged and apologised for the omission. It said that it was not a deliberate omission, but that it might be explained by the discussion (documented in the medical record) that Dr Greene, the medical registrar on-call on the morning after the fall, had with Mr Brown's family, where they had agreed that the patient was to be kept comfortable and was not for resuscitation. The HSE said that the Medical Intern on Call, when attending Mr Brown after his death, and having noted this discussion recorded in the medical record, may have considered that a post mortem was unnecessary.
2.3.9 - Failure to consider Mr Brown's death at weekly case conference
The Hospital reported that Mr Brown's care was discussed at the weekly meeting; however, it said that minutes were not taken.
2.3.10 - Sometime after Mr Brown had died, the family was asked to leave the ward on the pretext that the hospital wanted to remove his body to the Mortuary. However six hours later, his body was still lying in the bed on the busy ward and had not been moved.
The HSE told my Office that, when a patient dies, every effort is made to ensure families can spend as much time as they require with their loved one. It said that families are asked to leave whilst the remains are being prepared for the mortuary. This usually occurs within the first hour of death. Once completed, families are left to sit with the remains for as long as they wish. The HSE advised me that none of the staff members interviewed could say for certain the time the family left the ward, but it was their opinion that it was unlikely that any of the staff members asked them to leave.
The HSE checked with the mortuary staff and the procedure in 2005 for the reception of remains did not include logging the time. However, it said that this practice has now changed and the time of reception is now logged.
2.3.11 - Visit from Tea Lady
The HSE admits that this incident may have occurred. It explained that the kitchen staff prepare breakfast and serve it accompanied by a nurse or care assistant who oversees the individual dietary requirements of each patient. It acknowledged that the catering staff member may not have been informed that the patient had died. The HSE said that, if this was the case, the hospital apologised and regretted any upset that this action may have caused to the family.
2.3.12 - Advice from the Consultant that their father could have had surgery
This claim was denied by the Consultant.
2.3.13 - Delay by the Hospital in signing the Medical Certificate of the Cause of Death (Appendix 5)
The HSE confirmed that the Death Certificate was signed 12 days after the patient died. The HSE do not regard this as a long delay.
2.3.14 - There was a delay of two weeks in notifying the Coroner of the patient's death
The hospital agreed the Coroner should have been notified the morning the patient died and that he might have ordered a post mortem.