Chapter 6 - Recommendations

I welcome the HSE's positive response to my Draft Investigation Report on this case and the wide range of improvements the hospital has agreed to, both before and after receipt of it. These improvements, detailed in Chapter 5 of this report, include healthcare record keeping, communication, falls management and post mortem practices; the development of staff training, staff guidelines and patient information leaflets; and the implementation of an action plan for End of Life Care in Hospitals.

I intend to review progress / compliance with these initiatives over time. However, notwithstanding these very positive developments, I make the following recommendations:-

I recommend that Limerick Regional Hospital

• take steps to a) raise the awareness and vigilance of medical, nursing, and risk management staff to deaths which follow serious incidents, and b) ensure that serious incidents are followed with appropriate actions
• ensure that the patient’s medical team provide adequate guidance, in advance of periods of leave, to fully inform on-call staff who may be charged with making decisions regarding a post mortem
• review current complaint handling procedures 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
• publishes its complaint examination procedures on its website.

I also recommend that

• A member of the senior management team in Limerick Regional Hospital visit the Brown family to apologise, in person, 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.
• To assist in providing a remedy and closure for the Brown family, the findings of this investigation be drawn to the attention of key staff involved in the care of the late Mr Brown during his stay in the hospital.
• This Investigation Report informs a further review and updating of the relevant hospital procedures manuals, data capture processes and information systems.
• This Investigation Report is brought to the attention of the National Director for Quality and Care with a view to all hospitals taking cognisance of key learning points.

My Investigation Report was issued to the CEO of the HSE in June 2010 and I am satisfied that the HSE has accepted all my recommendations and devised an action plan to implement these in a timely fashion.