Date released: 13.12.2010
- Ombudsman, Emily O’Reilly, publishes Investigation Report about Limerick Regional Hospital and the care of a 61 year-old man who had suffered a stroke.
- Says “hospitals should improve facilities to give dying patients and their families, greater dignity and peace.”
The Ombudsman, Emily O'Reilly, today (13th December 2010) published a report into the care and treatment of a patient and his family at the Mid-Western Regional Hospital, Dooradoyle, Limerick. Her investigation involved interviews with a total of 13 doctors, nurses and administrative staff in the hospital. The daughter of the 61 year-old man complained to the Ombudsman about the care her father had received in the Mid-Western Regional Hospital. While in hospital for treatment for a stroke, her father suffered a fall from his hospital bed and suffered a broken tooth, an 8cm laceration to the back of his head and cuts to his tongue. He died 52 hours later.
The daughter was particularly concerned that a post mortem examination was not carried out on her father's remains. Although an inquest was later conducted by the coroner, she and her family were left not knowing whether the man had died from his illness on admission, or from complications caused by the bad fall. There was a delay of two weeks in the hospital notifying the coroner of the patient's death and they did so only then, the family believes, because of their contact with An Garda Síochána.
The family was also unhappy with the lack of safety measures taken to prevent the man from falling. The family did not see a call bell on their disabled father's bed when they visited him on the morning of his fall. The family was also unhappy with the treatment of their father after he died and the fact that, after the family left the ward, their father's body was left lying in his hospital bed on the busy ward and not moved to the mortuary for some considerable time. Ms. O’Reilly’s investigation found that much of the care given to the patient was of a high standard, but she was critical both of the hospital’s actions and inactions. She was particularly critical of the failure of hospital staff to consider and plan for a post mortem on the man, who, although having been admitted with a stroke condition, had suffered a bad fall and head injuries 52 hours before his death.
Commenting on her report, the Ombudsman said "In its initial response to my Office, the HSE said that the failure to undertake a post mortem in this case was an oversight on the part of the medical team. While this might have been the case, I believe as a minimum it is reasonable to expect that when a person dies in hospital, the question of a post mortem is at least considered by the patient's medical team and an informed decision made. If a patient is dying and the patient’s medical team is not going to be on duty for some time, as happened in this case, then I would expect that some direction be given in the medical notes, or to nursing staff who will be on duty, about the issue of a post mortem. While the consultant in question had already apologised to the coroner for his oversight in not drawing this death to the coroner’s attention, I was concerned that the hospital had not taken any action to prevent a recurrence of the failure to notify the appropriate coroner. "
The Ombudsman was also critical of the fact that there was no evidence that staff had undertaken a falls risk assessment of the patient, a person who was at obvious risk of falling. In fact, the Ombudsman’s investigation identified that the hospital had failed to comply fully with its own policy in this regard.
The Ombudsman found that there was an unacceptable deficit in record management practices. These related to the failure to retain some records, unauthorised changes to some records, and failure to record adequate information on the handling of the remains after the family had left the ward. The Ombudsman pointed out that this "represented poor practice generally, but also limited the evidence available to me for some aspects of my investigation."
The Ombudsman also reiterated her request, made in other public fora, that hospitals improve their facilities to allow dying patients and their families greater dignity and peace at the time of death. After a detailed investigation of the case, the Ombudsman sent her final Investigation Report to the HSE last July. The HSE accepted all the recommendations in the report and developed a comprehensive action plan to implement the recommendations. Included in the Ombudsman's recommendations were that Limerick Regional Hospital take steps to
- raise the awareness of medical, nursing, and risk management staff to deaths which follow serious incidents
- ensure that serious incidents are followed with appropriate actions
- ensure that there is seamless communication between medical teams, and on-call staff, particularly where there is the possibility of a post mortem being required
- review current complaint handling procedures
The Ombudsman also recommended that a member of the senior management team in Limerick Regional Hospital visit the family to apologise, in person, for the shortcomings identified in the report and to explain what action is being taken on foot of the report. Finally, the Ombudsman recommended that her Investigation Report be brought to the attention of the National Director for Quality and Care with a view to all hospitals taking cognisance of key learning points.
The Ombudsman welcomed the HSE's positive response to her Investigation Report and the wide range of improvements the hospital agreed to implement. The Ombudsman said that she intends to review progress/compliance with these initiatives over time.
Concluding, the Ombudsman commented
“This case is one of a growing number of complaints received by my Office which deals with care provided by the HSE and voluntary agencies providing services on behalf of the HSE. In a lot of cases, my Office receives comprehensive explanations and apologies for patients and their families and very importantly, assurances that steps have been taken to prevent the identified failures from recurring. I hope that this and other cases will alert the public to the potential of my Office to help people who feel that they have been treated badly in their interactions with the health service and who are unhappy with the treatment and care given."