Complainant not advised by the Clinical Nurse Manager that her mother had developed red pressure areas or blisters:
Factors contributing to the patient's deteriorating condition:
1) Relevant background information:
2) Lack of nutrition, hydration, refusal to allow family syringe-feed their mother, and failure to have an assessment carried out by the Speech and Language Therapist:
3) Lack of seating:
4) Turning Regime:
5) Medication:
6) Refusal to supply two antibiotic tablets on going home:
7) Lack of information/contact with the complainant:
8) Difficulties in pursuing the complaint with the HSE:
9) Issues with regard to MRSA:
Complainant not advised by the Clinical Nurse Manager that her mother had developed red pressure areas or blisters:
Over a five year period, Mrs Moore had looked after her mother, she had never suffered from bed sores. On admission to St Mary's on Monday, 12 December, 2005, her mother's skin was assessed and recorded in the nursing notes as being intact and in good condition. She was assessed, however, as having a high Waterlow score of 22, (which meant that she was very susceptible to developing pressure sores). When her daughter brought her home on Thursday afternoon, 15 December, 2005 (three days later), she noticed that her mother had large black blisters on her sacrum, and on both her heels. This was confirmed by the woman who provided home help, who observed the blisters on Thursday evening, and who was present when Mrs Moore telephoned the Director of Nursing to make a complaint about her mother's condition. It was also verified by the Public Health Nurse, who attended Mrs Kelly at her home the following morning.
According to the Clinical Nurse Manager, while the complainant's mother had developed red pressure areas by Wednesday, 14 December, she did not have any blistering while she was in her care. The nursing records refer to Mrs Kelly's pressure areas being red on Wednesday, 14 December, and on Thursday, 15th, both her heels were very dark red in colour. The records indicate that her heels had been massaged during Wednesday night owing to their redness. The records also refer to the fact that Mrs Kelly had a bed bath on Thursday morning prior to her being taken home.
If blistering was present, at that stage, it was not recorded in the nursing records. The Director of Nursing stated that " the poor state of the patient's pressure areas was most likely a result of her nutritional and hydrational status, together with the fact that she had a chest infection".
In commenting on the draft final report, the Local Health Manager (LHM) stated that nursing staff were confident that, while Mrs Kelly had red areas on her sacrum and on her heels when leaving St Mary's, there were no blisters present. In response, I must point out that Mrs Moore advised my staff that her mother had been placed on a trolley in her bedclothes, without her nappy having been changed, before she left the Nursing Home. She wondered, therefore, how the nursing staff could be so confident about her mother's pressure areas.
It is difficult to reconcile the statement by nursing staff that the patient did not have blisters in St Mary's, with the evidence provided by Mrs Moore's Home Help, who assisted her in changing her mother's nappy on Thursday afternoon, and who witnessed her shock on discovering them. Regardless as to whether the blistering occurred before Mrs Kelly left the Nursing Home or not, I think it is fair to conclude that the nature of the care the complainant's mother received over the previous three days must have been a contributory factor in the development of the blisters. In her letter to Mrs Moore in January, 2006, the General Manager stated that it was her opinion that the level of care afforded to her mother, following her admission to St Mary's Care Centre, fell short of the standards of excellence which management and staff continually strive to achieve.
It is also fair to conclude that, on the balance of probabilities, the complainant was not advised by the Clinical Nurse Manager that her mother had developed red pressure areas before she took her home from St Mary's. The evidence in relation to this conclusion rests with the independent evidence provided by Mrs Moore's Home Help who said that she witnessed her shock on discovering them. In addition, while the nursing records refer to Mrs Kelly's pressure areas being red on Wednesday and very dark red on Thursday during her stay, there is no record in the nursing notes that the complainant was so informed, or of any reaction from the complainant on being so advised. It is not unreasonable to suggest that Mrs Moore, a qualified nurse, would have asked immediately to see the pressure areas had she been advised of their existence. Mrs Moore indicated that, had she seen the condition of her mother's pressure areas before taking her from home St Mary's, she would have immediately requested to speak to the Director of Nursing to make a complaint.
In commenting on an initial draft of this report, the Clinical Nurse Manager stated that she had advised the complainant that her mother's pressure areas were red, in the presence of a staff nurse, prior to her taking her mother home. While my staff had raised this issue previously, this was the first time that mention was made of another nurse being present when the complainant was allegedly informed about her mother's pressure areas being red.
My staff contacted this nurse who had since retired from St Mary's. She stated that she had given Mrs Kelly a bed bath on Thursday morning, and that she recalled that her pressure areas were a bit red, but that there was no broken areas of skin. She stated that she was present later that day when the ambulance men came to bring Mrs Kelly home, and that she had helped the Clinical Nurse Manager to lift Mrs Kelly onto the trolley. She said that she was one hundred percent certain that the Clinical Nurse Manager had advised the complainant about her mother's pressure areas being red, which she said was done shortly before the patient was placed on the trolley. When asked what the complainant's reaction was to this information, the nurse stated that Mrs Moore made no comment, and did not ask to see the pressure areas. The nurse stated that Mrs Kelly did not have any bed sores at that time.
The information provided by the retired staff nurse was at variance with that contained in the nursing records. The daily care flow chart indicated that Mrs Kelly received a bed bath on Thursday morning, but this was signed off by a different nurse. In addition, the nursing records indicated that Mrs Kelly's pressure areas were very dark red in colour on Thursday, and not just a bit red as stated by the staff nurse.
My staff discussed the information provided with Mrs Moore, who advised that her son was witness to the conversation between herself and the Clinical Nurse Manager at the time she was taking her mother home. She had phoned her son requesting him to drive her car home while she travelled in the ambulance with her mother. Mrs Moore stated that the Clinical Nurse Manager had pulled the curtain screen around her mother, and with the aid of the two ambulance men, had placed her mother on the trolley. The complainant said that she stood outside the curtain area, along with her son, while her mother was being placed on the trolley. She stated that there was no other member of staff present, and that there was little conversation between herself and the Clinical Nurse Manager at that stage. The complainant's son confirmed this in writing to me, and stated that there was no other member of the nursing staff present at the time that his grandmother was put on the trolley.
In commenting on the draft final report, the Local Health Manager said that
"the report all but dismisses the evidence provided by the staff nurse who was a witness to these discussions. Doubts are cast on her evidence on the basis that this nurse stated that she had given Mrs Kelly a bed bath prior to her going home and a different nurse signed the daily care flow chart. However, a bed bath is given by two nurses or a nurse and care assistant and only one staff member signs the chart. It is difficult to find the justification for accepting Mrs Moore and her son's recollection and dismissing the evidence of the Clinical Nurse Manager and the staff nurse. Throughout the report greater weight appears to be given to information provided by Mrs Moore than the reports and recollections of staff who were present on the ward."
I have carefully considered the Local Health Manager's comments. However, I remain of the view that the evidence gathered, on balance, supports the complainant's version of events.
In commenting further on the matter of the blisters, the Local Health Manager raised the issue as to why Mrs Moore had not mentioned the blistering during her first telephone call to the Director of Nursing on Thursday afternoon, after she had taken her mother home. In response, I must point out that Mrs Moore clarified that, on her arrival home, she felt compelled to phone the Director of Nursing immediately to complain about the general care and treatment her mother had received during her respite break. She telephoned her a second time, later that evening, when she had changed her mother's nappy, with the assistance of her Home Help, and discovered the severe blistering for the first time.
Factors contributing to the patient's deteriorating condition:
On admission to St Mary's on Monday, 12 December, 2005, Mrs Moore provided full details regarding her mother's needs to the nursing staff. These details included information with regard to her diet, her medication, and her daily routine of sitting out in an armchair with her feet elevated on a stool, to avoid pressure sores. She also supplied a selection of fortified drinks which her mother normally took at home. She advised that her mother was sometimes fed by syringe due to her swallowing difficulties, and brought in a sample dinner to show its consistency to the staff. She stressed that all her mother's food had to be liquidised and fluids thickened, and that her tablets (medication) were crushed and mixed through her porridge in the morning.
On admission, Mrs Moore also provided a letter from her mother's GP setting out details of her mother's diagnosis and medication. She supplied sufficient medication for her mother's stay. The Director of Nursing, however, advised that no information had been provided to St Mary's by the GP or Public Health Nurse, prior to her mother's admission, with regard to her swallowing difficulties or particular feeding needs. She stated that, had information with regard to Mrs Kelly's specific feeding requirements been provided to nursing staff in advance of her admission, the issues in relation to feeding could almost certainly have been reduced if not avoided.
Mrs Moore stayed with her mother on Monday afternoon and was allowed to feed her at tea-time with a syringe, which she had requested from the staff nurse on duty. On Tuesday morning, prior to going away, Mrs Moore visited her mother and asked for a syringe to give her mother a drink. On that occasion, she was refused a syringe by the same staff nurse, who indicated that syringe feeding was not allowed, as this was considered force feeding. This meant that the complainant's sister, Joan, who would have been available to syringe feed their mother during mealtimes in St Mary's, would not be allowed to do so either. Mrs Moore was concerned, at that stage, as to how her mother was going to receive food and fluids, and suggested that, if necessary, a nasal gastric tube be used, as this had been suggested by a speech and language therapist during a previous admission to the General Hospital. However, she said that she was reassured by the staff nurse that her mother would be well looked after, and would be seen and assessed by the Speech and Language Therapist. The complainant requested, before she left on Tuesday morning, that she be contacted should there be any concerns whatsoever regarding her mother, and left her mobile number along with that of her sister Joan.
2) Lack of nutrition, hydration, refusal to allow family syringe-feed their mother, and failure to have an assessment carried out by the Speech and Language Therapist:
The nursing staff stated that, prior to Mrs Kelly's admission, they were not made aware that she was syringe fed at home, and they were not accustomed to syringe feeding patients. The Director of Nursing stated that feeding by means of a syringe was not normal practice in the nursing home, and that if it was required, staff would need instruction from the Speech and Language Therapist. As a result, they said that they were faced with the dilemma of force feeding or not, a woman with an impaired ability to swallow, which could constitute elder abuse, and also cause her serious further illness. I accept that prior information regarding Mrs Kelly's swallowing difficulties would have been beneficial for nursing staff. Nevertheless, having observed how Mrs Kelly was fed by her daughter on Monday evening, I would have expected that a public nursing home facility should have had adequate procedures in place to respond appropriately to this elderly woman's needs. In the event that nursing staff felt unable to provide adequate care, given the particular circumstances of Mrs Kelly's needs, they should have advised Mrs Moore accordingly rather than reassure her that her mother would be well looked after.
In commenting on the draft report, the Local Health Manager said that Mrs Kelly was very ill upon admission, and was already suffering from a respiratory tract infection. He stated that because her chest was very congested, concerns were raised about the appropriateness of syringe feeding, and the high risk of her aspirating during this process. In response, I must point out that Mrs Kelly's GP had not prescribed antibiotics for her before her admission, and the Medical Officer in St Mary's did not prescribe antibiotics for her chest infection either until Wednesday afternoon. This was despite the fact that he had examined her on Tuesday morning. He did not suggest referring her to the General Hospital until the complainant sought to take her mother home on Thursday morning. Had Mrs Kelly been very ill on admission, I would have expected the Medical Officer to have taken appropriate action on Tuesday morning. Mrs Moore said that her mother was always chesty, but this did not hamper her being fed by syringe. If the medical and nursing staff considered that Mrs Kelly was at high risk of aspirating during the process, they should have taken steps to ensure that she was nourished and hydrated using an alternative method, or notified Mrs Moore that they could not feed her.
The Director of Nursing has acknowledged that the complainant's mother received very little by way of food or fluids during her stay. No record was kept of Mrs Kelly's fluid output on Tuesday. On Wednesday, when the Medical Officer noted that her condition had deteriorated, and that Mrs Kelly was dehydrated, he ordered that she receive fluids through a subcutaneous drip, which only commenced on Wednesday afternoon. The Medical Officer also commenced Mrs Kelly on a course of antibiotics for a chest infection, which was administered via injection, and requested that her fluid output be checked and measured. During the interview with my staff, the Medical Officer stated that there were no cultures in Mrs Kelly's urine at that time, and there was no indication that she was suffering from a urinary tract infection. He indicated that Mrs Kelly had a catheter in place which could make a patient prone to infection, but there was no evidence to indicate that she was suffering from same. When asked by my staff as to whether he was concerned, at that stage, regarding Mrs Kelly's nutritional intake, the Medical Officer advised that he was more concerned about her hydrational status, and that nasal gastric tubes were not easily tolerated. He said that he would have only have considered this option as a last resort. Mrs Kelly developed a high temperature on Wednesday evening, and Paralink (a paracetamol solution) was administered to help bring it down. However, the complainant made the point that no blood tests were carried out to determine the cause of her mother's high temperature.
In commenting on a draft of this paragraph, the Medical Officer responded that a blood test would not have determined the cause of the patient's high temperature. However, the complainant commented that a blood test would have shown whether her mother's white cell count was raised, which would have indicated that she had an infection.
On Thursday evening, after she had taken her mother home, Mrs Moore called a doctor from Midoc, whom she said advised her that her mother was dehydrated, that she did not have a chest infection, but that she had a urinary tract infection. In commenting on this issue, the Medical Officer queried whether there were laboratory findings to back up this information. Mrs Kelly's GP was able to confirm that he had received notification from Midoc that Mrs Kelly had been treated with Siproxin for a Urinary Tract Infection following her return home from St Mary's.
In relation to the assessment by the Speech and Language Therapist, the General Manager acknowledged that the patient was not assessed at all during her three days respite, although an assessment was ordered, and should have been carried out. This arose because the Medical Officer had not signed the request form on Tuesday morning which he was aware he was required to do. Even if the Medical Officer had signed the form, however, it would not have been acted upon as the Speech and Language Therapist did not return to the ward to collect it on Wednesday, as arranged.
The Clinical Nurse Manager said that she had tried to phone the Speech and Language Therapist on Wednesday afternoon, but was unable to contact her on the landline, and that she had not left her mobile phone number with nursing staff. In the absence of the assessment being carried out, and in view of the fact that the Clinical Nurse Manager was unable to make contact with the Therapist, it would seem reasonable that a member of the family, who was present and prepared to syringe feed her mother, should have been allowed to do so. This would have been more acceptable than allowing the patient to go without adequate food or fluids for a period of almost two days.
It is apparent that there was a lack of clarity with regard to the process of referring a patient for speech and language therapy. The Medical Officer, who requested the referral, would have known from past experience of the protocols in relation to the signing of the referral form, which was essential for the assessment to be conducted. He stated that he would have expected the assessment to be conducted whether the form was signed or not, which was clearly not the case.
In commenting on a draft of this paragraph, the Speech and Language Therapist made the point that nursing and medical staff were routinely made aware of the need for dysphagia referrals to be signed by the GP, according to professional standards set, and she submitted documentation to my Office which supported her position. She advised that numerous letters and memos were circulated explaining this requirement when she took up her position in St Mary's in September, 2003. She confirmed that the referral process was discussed on several occasions with management and the Medical Officer at the nursing centre, and she stated that clients referred for a dysphagia assessment were not assessed in the absence of a signed referral. Any dysphagia referrals that were unsigned or signed by nursing staff once identified, were returned to the ward. The Speech and Language Therapist stated that it was sometimes necessary for her to instigate SLT referrals following clinical observations, and that on some occasions it could take up to a week or more for a requested referral to be signed by the Medical Officer. In a small number of instances, the request would not be approved. Therefore, she held the view that contacting the Medical Officer to "fast track" the referral was unlikely to have been productive in relation to Mrs Kelly's case. She added that the Medical Officer had the ultimate responsibility for the patient's medical well-being, and he was fully aware of the protocols of referral.
There was also a breakdown in communications between the nursing staff and the Speech and Language Therapist on the Wednesday. According to the nursing staff, had the Speech and Language Therapist returned to the ward on Wednesday, as arranged, Mrs Kelly would have been assessed. However, in commenting on a draft of this paragraph, the Speech and Language Therapist stated that while she had agreed to call on the Wednesday to collect the referral, she did not agree to assess the client. She explained that referrals were routinely collected, recorded and prioritised before assessment occurred. She said that the service that she provided to St Mary's, at that time, had no formal structure to deal with respite cases. Long-term care was not an acute setting, and was viewed as a community based service. The benchmark for response time for dysphagia referrals was contact within two weeks of receipt of referral.
The nursing staff indicated that, had the speech and language assessment been carried out, they could then have been instructed as to how best to proceed with feeding the patient. The Clinical Nurse Manager stated that she tried to make telephone contact with the Speech and Language Therapist on her landline, as no mobile contact had been issued to nursing staff at ward level.
In commenting on a draft of this paragraph, the Speech and Language Therapist stated that she had provided details of her landline (which had a voicemail facility) and her mobile phone number to nursing staff when she took up her position in 2003. These details were also contained on the safe feeding guidelines which she had issued to all nursing staff, and she submitted a copy of same to my Office. She said that she was in and out of the Office on the Wednesday in question, dealing with other service demands, and that no message was left for her on her landline, and no note was left for her, and no phone contact was made.
The Speech and Language Therapist advised that liaison with other staff could have occurred but did not. She clarified that she was in the Occupational Therapy Room in St Mary's all Wednesday afternoon facilitating the Christmas event for patients, and that since commencement of her post her role was to organise attendance, provide all administration support, and to include and facilitate patients with specific communication difficulties to participate in social and communicative interchange. She added that her involvement in this event was well publicised, and she forwarded information which was available to nursing staff detailing her position in St Mary's on that day. She said that, in the event of an emergency situation, the Therapist in the acute hospital could have been accessed, as was the practice when she was on leave of absence on occasions.
The Speech and Language Therapist also commented that the nursing staff had not conveyed sufficient information to her regarding Mrs Kelly's swallowing impairment and food modification. She said that when a nurse contacted her during the period in question, the emphasis was specific to the appropriateness of syringe feeding, as Mrs Moore had requested this. She said that she was not informed of any specific details, such as the patient's medical, physical or cognitive status, and that she was led to understand that some level of spoon-feeding was continuing. She pointed out that she was not made aware that syringe feeding was to be discontinued, nor was she aware of the patient's risk to pressure areas, or her inability to take medication orally. The focus of the nurse's contact with her was on syringe feeding, she said, and nutritional compromise or at risk factors were not raised at anytime. She added that the central issue was one of nutritional intake, in what she subsequently understood to be a complex case. She stated that had she been privy to the central issues, including the pertinent clinical information, she would have seen a need to prioritise this patient. It is my view, given the nature of Mrs Kelly's problem with nutritional intake, that the Speech and Language Therapist should have returned to the ward on Wednesday to collect the signed referral as she had agreed to do. It is also my view that the Clinical Nurse Manager should have ensured that she had the Therapist's contact details and mobile telephone number readily to hand, in the event of an emergency situation arising on her ward, and should have been more proactive in ensuring that an urgent message was left for her in relation to Mrs Kelly. If and when contact could not be made by telephone with the attending Speech and Language Therapist, then, under the circumstances, the Clinical Nurse Manager should have sought urgent advice and assistance from the therapist based in the acute hospital.
The Director of Nursing stated that it could be questioned why a decision was not taken to transfer Mrs Kelly to the General Hospital when the Speech and Language Therapist could not be contacted on Wednesday afternoon. She added that nursing administration should also have been contacted for advice and informed of the situation.
The General Manager accepted that the failure to complete an assessment of such an elderly patient resulted in an unacceptable lapse in the quality of care provided to her. She said that this was primarily as a result of poor communications across a number of disciplines involved with the provision of care. On foot of this complaint, the Care Centre has put in place measures to ensure that all members of staff are made fully aware, through training, of the protocols involved in the referral process and adhere to same.
3) Lack of seating:
Mrs Kelly was not taken out of bed during her stay, as requested by her daughter, due to the fact that the Occupational Therapy Department (OTD) did not have adequate seating available. The complainant made the point that she used to sit her mother out at home each day in an ordinary armchair with cushions. There were chairs in the OTD, but these required repair, and were unfit for use. Efforts were made to locate suitable spare chairs around other wards, but none were available. Adequate seating is a basic requirement within all nursing homes and centres. The OTD should have ensured that adequate seating was available, on request, at all times. The patient would have benefited from sitting out, as she did at home, and this would have helped to relieve her pressure areas. The Manager of the OTD advised that a range of adaptable chairs had since been repaired, and two highly adaptable chairs specifically for respite services had been ordered, so that a sufficient supply of suitable seating would be available at short notice for patients in future.
4) Turning Regime:
The Director of Nursing stated that the skin integrity of a patient is assessed on admission, and an appropriate plan of care is then devised. She said that with each intervention with the patient, the nurse monitors and assesses the patient's condition and uses their clinical judgement to determine appropriate turning and treatment. The complainant's mother was initially assessed as requiring to be turned every three hours, as she was being nursed on a Pro-2000 mattress (high grade air mattress). However, by Wednesday, when Mrs Kelly's pressure areas deteriorated, her turning regime was not altered, and according to the nursing records, she continued to be turned at three hourly intervals.
The Director of Nursing stated that she could only assume that a decision was taken to maximise potential for as much rest as possible during the patient's last night in St Mary's, as she was clearly ill.
In commenting on a draft of this paragraph, the Director of Nursing referred to literature which suggested that the re-positioning of patients had no preventative effect on the development of grade 1 pressure ulcers. She stated that "high risk" was determined not only by the force of pressure exerted on the skin, but also by the patient's general health status, and nutritional state. However, the Director of Nursing also submitted literature to me which listed the top ten tips for preventing pressure sores, and these included the regular turning and changing of position at two hourly intervals. It also gave advice about moving a patient safely without risking further damage to the skin. Interestingly enough, one of the top tips advised against rubbing or massaging the skin, and I note from the nursing records that Mrs Kelly's heels were massaged during Wednesday night, due to them being red. This is an aspect of care which should be reviewed in light of the advice and contents of the literature.
It would also appear that nursing staff should have considered altering Mrs Kelly's turning regime during Wednesday night to reflect her changing needs, particularly when it was apparent that her pressure areas had noticeably changed colour.
5) Medication:
When Mrs Moore's mother was admitted to St Mary's, the Medical Officer continued to prescribe her medication as per her GP's prescription with the exception of Combivent nebules, (drugs administered through a mask which the patient inhales to relieve chestiness) which he prescribed twice daily as compared to three times daily. However, he did advise nursing staff that the dosage could be increased to the usual three times daily, if warranted. Mrs Moore questioned why the Medical Officer altered her mother's dosage during her stay in the Care Centre, and was concerned that her mother had become extremely chesty as a result of administering the lower dosage. The prescription of medication for a patient is a clinical issue, which I am not empowered to examine.
Mrs Moore advised the nursing staff that all of her mother's tablets, which she had provided, had to be crushed and mixed through her food. The nursing records indicate that Mrs Kelly's tablets were crushed and mixed with yoghurt, which she took from a spoon. The records were signed off that the patient had taken all her medication. In commenting on the draft final report, the Local Health Manager stated that Mrs Kelly's medication was signed for and recorded as having been administered, and to conclude otherwise was to suggest that the nursing staff falsified records. In response, I must point out that the nursing staff reported that, while thickened fluids and liquidised food were offered and encouraged to the patient by means of a spoon, very little was accepted. (This would be understandable given that Mrs Kelly was not used to being spoon-fed due to her swallowing impairment). The Clinical Nurse Manager also stated that the patient would not open her mouth. In this context, it is very difficult to understand how the conclusion could be reached that the complainant's mother consumed all of her medication.
The HSE's Investigation Report indicated that it is the usual practice in St Mary's for medications to be administered from the patient's own supply, and any medications unused are returned to the patient before going home. Mrs Moore had expressed concerns about the level of medication administered to her mother, owing to the fact that she was not accepting food from the spoon into which her tablets had been crushed. These concerns were reinforced by the high number of tablets which she said were returned to her on taking her mother home (which included 5 Lasix, 5 Nu-seal aspirin and 26 Combivents). Furthermore Mrs Moore said that, before she took her mother home on Thursday afternoon, she raised the question with the Medical Officer and the Clinical Nurse Manager as to why her mother's Lasix (diuretics which help to flush out fluid particularly around the heart) had not been administered via injection, when she had been refusing food and medication from a spoon. Mrs Moore alleged that both members of staff just looked at each other and said nothing. During the interviews with my staff, the Medical Officer and the Clinical Nurse Manager both confirmed that Mrs Kelly had received her Lasix tablets, which they said had been crushed along with her other medication, and given to her in yoghurt. They said that they could not recall Mrs Moore raising the issue with them regarding her mother's Lasix, or how they had been administered to her mother. However, in commenting on a draft of this paragraph, the Medical Officer stated that it had been explained to Mrs Moore that Lasix would have made her mother's hydrational status worse. The only reasonable conclusion which can be drawn from the Medical Officer's comments is that Mrs Kelly did not, in fact, receive her Lasix medication while she was a patient in St Mary's. I note, with concern, that the Drug Prescription and Administration Sheets had been signed by the nursing staff to the effect that Mrs Kelly had received all of her medication, including her Lasix, during each day of her stay in the Nursing Home.
In relation to the dispensing of medication, the Director of Nursing explained that while patients are asked to bring in their own medication for their use during respite care, it is the practice for the dispensing nurse to provide patients with tablets from the medicine trolley, if the nursing home has them in stock. This, it was suggested, could account for the return of a high number of Mrs Kelly's own tablets on her being taken home. The Director of Nursing also confirmed that medicines were signed for by the dispensing nurse when undertaking the medicines round.
Notwithstanding the explanation concerning the amount of tablets returned to the complainant on taking her mother home, I feel that it is reasonable to conclude that Mrs Kelly could not have received the required dosages, given the Medical Officer's own admission, and the feeding difficulties that occurred during her stay.
6) Refusal to supply two antibiotic tablets on going home:
When the complainant went to take her mother home on Thursday afternoon, she was advised against doing so by the Medical Officer, who advised that her mother should be transferred to the General Hospital. The Medical Officer had commenced Mrs Kelly on a course of antibiotics the previous day for a chest infection. The complainant requested that she be provided with two antibiotic tablets for her mother to carry her over until she got a prescription the next morning from her GP. Her request was refused by the Clinical Nurse Manager who stated that it was not the practice to supply tablets to patients going home. The Medical Officer, at the interview with my staff, explained that it would have been unethical of him to supply medication for a patient who was being taken home against his medical advice, and who was no longer under his care. The Medical Officer stated that he had strongly recommended that the complainant's mother be transferred to the General Hospital, but Mrs Moore had insisted on taking her home. In a further comment, the Medical Officer stated that in taking her mother home at midday, Mrs Moore had ample time to visit her GP, and the chemist which opened until 9.00pm. However, Mrs Moore did not arrive home with her mother by ambulance until approximately 3.30pm, as there were delays in obtaining an ambulance to transport her.
My Office raised the matter with the medical staff at the Department of Health & Children, and were given to understand that it was the practice in nursing homes and hospitals to provide tablets to patients to cover them on discharge, especially if it was considered that the patient might not get to see his or her GP that same day. Enquiries of other healthcare professionals in public nursing homes with relevant experience supports the position that patients receive sufficient medication on discharge, to cover them until they get to visit their own doctor. It appears that there are no written guidelines to direct Medical Officers on this issue.
Mrs Moore said she had left her mobile number with nursing staff for them to contact her should they encounter any difficulties in relation to her mother's care. She stated that she phoned St Mary's on Tuesday evening, and was told that everything was fine. On Wednesday evening, her sister Joan (who had stayed with her mother throughout Tuesday and Wednesday afternoon), phoned her to convey her deep concerns about Mrs Kelly's condition. Mrs Moore immediately contacted the ward, and said she was advised that her mother had a chest infection and had been placed on a drip. She said that she was given reassurances regarding her mother's condition, and was advised that she was receiving her medication by syringe. Mrs Moore told the nurse that she intended to take her mother home the following day. She felt that she should have been advised by the nursing staff about her mother's deteriorating condition when she rang on Wednesday evening, and no mention was made to her about her mother being transferred to the General Hospital.
In response to this issue, the nursing staff stated that procedures had been put in place to overcome the difficulties with regard to feeding Mrs Kelly, and they had hoped to have the benefit of the Speech and Language Therapist's assessment by Wednesday 14th. The nursing staff stated that they did not contact Mrs Moore on her mobile because they were aware that she, as principal carer, was availing of respite. However, the nurses said that they did explain to her sister, Joan, how their mother was progressing, and outlined that they had sought physiotherapy, speech therapy, occupational therapy and chiropody assessments for her.
They stated that they understood from Mrs Moore's sister that she would inform Mrs Moore of her mother's condition, and added that it would be considered normal practice for communication to be shared between family members. While I acknowledge the motivation of the nursing staff in not contacting Mrs Moore, I feel it is reasonable to conclude that, on balance, they should have phoned her, as Mrs Kelly's principal carer, at the earliest opportunity, given her specific request that she be so contacted. This would have provided an opportunity for them to outline the difficulties they were having in caring for her mother, and to explain what steps were being taken to overcome these issues.
8) Difficulties in pursuing the complaint with the HSE:
When the General Manager wrote to Mrs Moore on 17 January, 2006, on foot of her written complaint, she indicated in her letter that the complaint had led her to initiate a review of existing procedures in relation to patient care. The General Manager invited Mrs Moore to telephone her if she wished to discuss the issues further. Mrs Moore responded on 30 January, 2006, indicating that she found the contents of the General Manager's letter to be inadequate, and advised her that she had also written to the Community Services Manager, enclosing two photographs of her mother's pressure areas. She requested a meeting with the General Manager, the Community Services Manager, and the medical and nursing staff in St Mary's who were responsible for her mother's care.
Following this request, Mrs Moore said that she heard nothing further from the General Manager, although she called in person to see her, and tried on a number of occasions to talk to her over the phone. She stated that the General Manager was never available, according to her staff, and that she did not return her calls. Mrs Moore said that she then contacted the former Local Health Manager, and explained that she was getting no response from the General Manager, who was supposed to be investigating her complaint. The Local Health Manager apparently agreed that he would contact the General Manager on her behalf. Mrs Kelly sadly passed away on 24 March, 2006.
On 27 March, 2006, Mrs Moore received a second letter from the General Manager, referring to previous correspondence and phone calls in relation to her complaint, and advised her that the review of the case was being completed. She further advised that a copy of the final report would issue to Mrs Moore the following week, and that a meeting would then be arranged to discuss the contents. By 26 April, 2006, when Mrs Moore had not received the promised report, she contacted my Office seeking assistance in pursuing her complaint.
In commenting on the above criticisms, the General Manager stated that the reason the first draft was not sent to Mrs Moore as promised in her letter dated 27 March, 2006, was due to the fact that her mother had just passed away. She advised that Mrs Moore was in direct contact with the Community Services Manager, on an ongoing basis, and was kept fully informed of the progress of her complaint. She submitted a log of events which outlined the interaction between staff within the HSE, and between the HSE and the complainant. However, this log did not support the contention that contact had been made with Mrs Moore during the critical period from 30 January to the end of March, 2006, while her mother was still alive. The General Manager added that Mrs Moore was aware that the review was taking somewhat longer than was first anticipated and had accepted this. Notwithstanding any contact Mrs Moore may have had with the Community Services Manager, I feel that it was poor administrative practice on the part of the General Manager not to return any of the complainant's calls during the period January to March, 2006, particularly when she had invited Mrs Moore to contact her in her original letter.
In commenting on the draft final report, the Local Health Manager stated that while Mrs Moore may not have been in direct contact with the General Manager, she was in communication with the Community Services Manager and his staff, who were dealing with the matter on the General Manager's behalf. He said that insufficient mention was given to the General Manager's submission to my Office to this effect. In response, I wish to reiterate that the submission made to my Office does not support the contention that there was ongoing telephone contact between the complainant and the Community Services Manager. There is a record of only one telephone conversation having taken place between them dated 25 January, 2006. The General Manager's submission reveals that the final version of the review was not fully completed when she wrote to the complainant on 27 March, 2006, as two responses were still outstanding, so it would not have been possible to issue the final version to Mrs Moore the following week, as promised.
Following contact from my staff, a copy of the HSE's Review Team's Report was ultimately forwarded to Mrs Moore by the Community Services Manager on 11 May, 2006. He sought Mrs Moore's observations regarding the contents of the report, and advised her that arrangements would be made for her, and her sister Joan, to meet with nursing management (including the Clinical Nurse Manager) to discuss their concerns.
A meeting was subsequently arranged for 29 June, 2006. However, the Clinical Nurse Manager declined to attend the meeting on that day, at the last minute, as she anticipated that it might prove confrontational. In commenting on this issue, the Director of Nursing stated that the meeting with the complainant had been scheduled without prior consultation and agreement with the Clinical Nurse Manager. She recalled how Mrs Moore clearly blamed St Mary's and the staff, particularly the Clinical Nurse Manager, for her mother's death when she met her on the day of the proposed meeting. She said that it was inappropriate for this meeting to have been arranged without adequate consultation with that member of staff, or having an agreed statement of the terms of reference as to how the meeting would be conducted. She added that the short meeting that did take place was hostile and confrontational, and clearly not in the best interest of the staff member concerned. The Community Services Manager said that he supported the Clinical Nurse Manager in her decision, indicating that if the meeting became confrontational, it would not benefit either of the parties. The complainant commented that she was annoyed that the Clinical Nurse Manager was not present, as she had been given a legitimate expectation that she would attend.
It is generally accepted as good practice for members of staff involved with the direct provision of care to meet with complainants if so requested, as they would be in the unique position to explain what happened or to answer specific questions. It is also understandable that if it is perceived that such a meeting might prove inordinately confrontational, then the value of same can be lost with little gain by either side. The handling of nursing complaints are generally the overall responsibility of the Director of Nursing, who would have access to all of the nursing records, and could discuss the issues with all of the nursing staff involved in the patient's care.
Nevertheless, on balance, it would seem that the presence of the Clinical Nurse Manager at a meeting with the complainant and her sister would have been beneficial for the reasons outlined above. Should the meeting have proved to be inordinately confrontational, it would have been open to the staff members involved to withdraw from it. The Local Health Manager, in commenting on the draft final report, stated that he did not accept that the presence of the CNM at the meeting with the complainant would have been beneficial, and had she felt compelled to withdraw from it, this would have further damaged the communication process. However, I continue to hold the view that it would have been preferable for the CNM to have attended the meeting, which could have helped to bring closure to the issues being raised.
9) Issues with regard to MRSA:
A swab from Mrs Kelly's right heel tested positive for MRSA in January, 2006, almost one month after she had left St Mary's. As mentioned in this report, she had to have this particular heel debrided (cleaned and dead skin removed) on three occasions in the General Hospital following her return home. During the course of her complaint, Mrs Moore raised the issue as to whether nursing staff in St Mary's were taking precautions to avoid the spread of MRSA. She said that there was no handwash at the sink on Monday evening, when she went to wash her hands, and there were no signs around the ward advising visitors to wash their hands. In addition, there did not appear to be any disposable gloves or aprons on the ward.
In response to this issue, the Director of Nursing advised that there was an MRSA policy in place in St Mary's, and forwarded a copy to my Office. She said that she was satisfied that "Cutan", a proprietary handwash and moisturiser was available at all sinks throughout the Care Centre, and was kept liberally in stock should it need replacing. She also confirmed that it was replaced immediately the dispenser became empty. In addition, the Director of Nursing stated that Mrs Kelly was placed in a bed beside a doorway close to where alcohol gel was positioned on the wall. She stated that there had been no incidence of MRSA related infections or illnesses on Mrs Kelly's ward in a number of years.
It would not be feasible for me to determine where the late Mrs Kelly contracted MRSA. As I understand it, MRSA can be obtained even through a small pin hole in the skin. A swab of the infected areas would have had to be taken within 24 hours of Mrs Kelly leaving St Mary's in order to determine if it was actually present at that time.
There is conflicting information with regard to the availability of handwash on the Ward. While Mrs Moore and her sister both stated that they had not seen any handwash on the ward, the Director of Nursing said that it was there. It is crucial that handwash is widely made available at ward level, and that dispensers are replenished immediately they become empty, given that handwashing is one of the most effective methods of preventing the spread of MRSA in nursing homes and hospitals. It is also extremely important for nursing homes, as well as general hospitals, to display notices reminding staff and visitors alike that they must wash their hands.