Published December 2011
In order to protect the identity of the family in this case, all names have been changed.
The family of an elderly resident of St. Mary’s Hospital, Phoenix Park, Dublin, (a HSE nursing home) complained to the Ombudsman about her care while resident there. They complained about their mother’s personal hygiene, the management of her falls risk (she had a number of falls over a short period towards the end of her life) and the level of social and therapeutic activity offered to her while she lived there. They also complained of poor communication with them at the time of her death, and about failures to arrange a post-mortem which was requested by them. Failings around the request for postmortem meant that, ultimately, the donation of their mother’s brain to medical science did not take place. This distressed the family.
Mrs McCarthy (not her real name) was eighty one years old when she was admitted to St. Mary’s. She suffered from Alzheimer’s Disease and her cognitive function and ability to communicate were impaired. Accepting that the management of Mrs McCarthy’s falls risk, and her care generally, presented considerable challenges due to her advanced dementia, and also recognising the efforts by individual nurses within the constraints of the hospital’s infrastructure, the Ombudsman found a number of problems with her care.
Regarding falls prevention, the Ombudsman found that while informal assessments took place, formal reassessments of falls risk did not happen as they should have under the home’s policy. She also found that there was a failure to assess, within a system for doing so, the need for extra supervision for Mrs McCarthy. Having taken expert advice on the matter, the Ombudsman had concerns about night time staffing levels in the particular unit in which she lived, given its layout and the highly dependent patient profile at the time. The Ombudsman wrote to HIQA in this regard, providing a copy of her report.
The Ombudsman found that the medical staff at the hospital failed to communicate well with the woman’s family at the time of their mother’s death, and that this caused confusion and upset. Furthermore, she found that not all relevant information was provided to the Coroner by the doctor on duty.
The investigation found that procedures around information and consent for brain-banking were not followed by the medical personnel involved, despite their being available, and that due to poor administrative arrangements and communication, neither a postmortem nor brain banking happened although it was the family’s wish that they would take place.
With regard to personal hygiene, the Ombudsman acknowledged that the woman posed challenges for staff due to her condition. Nonetheless, the investigation found that showering of patients on the unit was limited due to the fact that there is only one shower for twenty-eight residents. She questioned whether St. Marys had made adequate provision in this area.
While the Ombudsman acknowledged one-to-one attention given to Mrs McCarthy by individual staff members, she found that there was no specific provision for her as a person with dementia, and that she was not provided with sufficient activities appropriate to her capabilities. An analysis of the records showed that Mrs McCarthy was documented as having participated in organised actives on 23 occasions over eighteen months. There was no comprehensive assessment of her needs.
On the matter of communication with Mrs McCarthy’s family, deficits were identified at the time of her death and afterwards. The Ombudsman found that the Senior House Officer on duty did not engage with the family when she attended their mother one hour prior to her death, and did not explain their mother’s condition to them. This was despite the fact that she had prescribed morphine to make Mrs McCarthy comfortable, anticipating that her death was imminent. The doctor in question was in her first post as a medical SHE and did not have any experience of dealing with the families of dying prior to working at St. Mary’s. She has apologised to the family for any distress caused.
The Ombudsman made detailed recommendations on the various areas dealt with in this case to the HSE, all of which have been accepted. They include:
The Ombudsman welcomes the HSE’s acceptance of her recommendations, and is committed to following up on their implementation.
The complaint to the Ombudsman which resulted in this investigation was made by the family of the late Mrs Mary McCarthy, formerly of Dublin. Mrs McCarthy had lived, for the eighteen months prior to her death, at St. Mary’s Hospital, Phoenix Park, Dublin 20 (St. Mary’s). She was eighty one years old when she was admitted to the hospital. She suffered from Alzheimer’s disease and, at the time of her admission, her cognitive function and ability to communicate was impaired. She had a mini-mental test score of 10/30, which indicated a high level of cognitive impairment. There is anecdotal evidence from medical and nursing staff that her cognitive function diminished further towards the end of her life, although this was not assessed again formally. While at St. Mary’s, Mrs McCarthy exhibited high levels of agitation and aggression at times. Prior to her admission to St. Mary’s she had been living alone, but was assisted daily by her family. The main reasons for her admission to long term care were her family’s concern for her general safety, her progressive dementia, her tendency to wander, and risk of falling. On admission to St. Mary’s, in June 2007, she was assessed as being at high risk for falls. Physiotherapy assessment notes at the time of admission show that she had fallen at home at night and that the number of such falls was increasing. While at St. Mary’s, Mrs McCarthy had a tendency to move about constantly, particularly when she was agitated. Her family was reluctant to have her restrained in any way. The former Director of Nursing told the Ombudsman that she was considered to be a maximum dependency resident due to her cognitive ability and lack of safety awareness. Mrs McCarthy died on 24 November 2008.
St Mary’s is a HSE (public) residential facility for the care of older people. It also provides services to adults under 65 years of age who have neurological conditions necessitating residential care. It has 382 beds, of which 257 are designated beds under health legislation [Health Act (2007) Care and Welfare of Residents in Designated Centres for Older People Regulations 2010]. In her submission dated January 2011, in response to draft extracts of this report which were provided to her, the former Director of Nursing told the Ombudsman’s Office that at the time Mrs McCarthy was resident at St. Mary’s, 47% of the residents were considered to be maximum dependency residents, 30% high dependency, 20% medium dependency and 3% were low dependency.
St. Mary’s has particular relationships with two Dublin hospitals - the Mater Misericordiae (the Mater) and Beaumont Hospital. Prior to the commencement of the Nursing Home Support Scheme in October 2009, a Consultant Geriatrician from Beaumont Hospital, had designated beds in the hospital. That Consultant continues to act as Consultant Geriatrician for patients admitted from Beaumont Hospital through the Local Placement Forum which, under the Nursing Home Support Scheme, assesses the needs of those applying for long term residential care. The Beaumont Hospital Consultant was Mrs McCarthy’s Consultant Geriatrician for most of her time at St. Mary’s, that is, for the time she lived on Rhiannon ward (14 September 2007 to 24 November 2008). Rhiannon Ward is in the old part of St. Mary’s hospital in a building which dates to the eighteenth century. It is comprised of six rooms accommodating 28 patients. Mrs McCarthy slept in an eight-bedded room.
On 6 January 2009, the Ombudsman received a letter of complaint from the late Mrs McCarthy’s family. The complaint, which had also been copied to St. Mary’s, related to Mrs McCarthy’s care and treatment while at St. Mary’s, and to failures of procedure and communication following her death which caused them distress. The family had made a complaint to St. Mary’s, to which the hospital had issued a reply. Subsequently, the then Director of Nursing convened a meeting with the family (on 16 January 2009). The meeting was attended by herself, the then Assistant Director of Nursing, a Clinical Nurse Manager from Rhiannon Ward and Mrs McCarthy’s Consultant Geriatrician. However, the family told the Ombudsman that they found the explanations offered to them at that meeting unsatisfactory and said that they had no confidence in the process. They requested an independent examination of the complaint by the Ombudsman’s Office. Having examined the issues in this case, the Ombudsman found that they were of a serious and complex nature. Given the seriousness of the issues raised, and the fact that the family was unlikely to be satisfied with a further response from the Hospital, the Ombudsman decided to carry out a preliminary examination of the complaint.
This Office wrote to the HSE on 23 March 2009, requesting a report on the issues raised. The HSE suggested that it would arrange an independent review in accordance with the provisions of the Health Act 2004 (Complaints) Regulations 2006 (the Regulations). As well as providing for an independent review by the HSE, the Regulations provide that anyone who is dissatisfied with a recommendation made, or steps taken in response to a complaint or a review, may refer the matter directly to the Ombudsman’s Office. Given the family’s position on the matter, the Ombudsman decided to continue the examination of the case.
The Ombudsman received submissions from the HSE on 28 April 2009, including submissions by the then Director of Nursing at St. Mary’s Hospital, and by the Consultant Geriatrician from Beaumont Hospital, along with Mrs McCarthy’s files and copies of procedures and policies in place at the time of Mrs McCarthy’s stay. Having examined those submissions, Investigators from the Office met with Mrs McCarthy’s daughters on 3 June 2009. They outlined the further explanations offered. The family members were not satisfied and told the Ombudsman officials that, in their view, the submissions did not give the full picture. The family members were disinclined to accept the hospital’s offer to meet with them again, as they did not feel it would be useful. Following that meeting, and having assessed all of the issues in this case, the Ombudsman decided to carry out an investigation under Section 4(2) of the Ombudsman Act 1980 as amended. The HSE was notified on 24 July 2009, and was provided with the Statement of Complaint which is attached at Appendix 1.
The Ombudsman Act 1980 provides that the Ombudsman may investigate any action taken by a Department of State or other public body (in this case the Health Service Executive (the HSE)), in the performance of its administrative functions, where it appears that the action has adversely affected a person (Section 4(2)(a)) and that the action was or may have been
If the Ombudsman finds that an action or inaction has led to such adverse effect, she will examine whether or not the public body has taken steps to remedy it. The Ombudsman also tries to ensure that public bodies deal with individuals properly, fairly and impartially.
It is important to note at the outset that the Ombudsman cannot, by law, examine actions taken by persons acting on behalf of the HSE which, in her opinion, are taken solely in the exercise of clinical judgement in connection with the diagnosis of illness or the care or treatment of a patient. The Ombudsman can, however, examine the administrative actions of healthcare professionals and administrators, taken in the course of clinical work, which do not involve such clinical judgements.
The Statement of Complaint provided to the HSE (at Appendix 1), had a number of elements. The complaint was that both the late Mrs McCarthy and her family suffered adverse effect due to deficits in her care and treatment, and to actions of the hospital following her death; and that such adverse effect arose out of one or more of the grounds set out in section 4(2)(b) of the Ombudsman Act 1980. The statement of complaint listed the following elements:
Mrs McCarthy sustained a number of falls in the weeks and days prior to her death. Her injuries included a fractured pubic rami (pelvic bone) and a fractured nasal bone. The family contended that the falls sustained, and resulting injuries, were due to inadequate steps having been taken to prevent falls, to inadequate supervision of Mrs McCarthy and poor management of her condition.
The family stated that communication between medical staff at the hospital and themselves was very poor, particularly on the day of her death. They said that this caused them distress. They said that it had also resulted in members of the family not having been called to their mother's deathbed, as the seriousness of her condition was not explained to them. In addition, the family said that poor and inappropriate communication by the hospital with the family, related to the donation of their mother’s brain tissue to Beaumont Hospital, caused them serious distress and ultimately resulted in the withdrawal of their consent for a post-mortem which they had originally requested. (The term "brain tissue", where it appears, means the whole brain. Medical personnel used this term during the investigation, whereas the family referred to "the brain". Both terms appear in this report
The family contended that the absence of protocols for the donation of brain tissue to the Brain Bank at Beaumont Hospital, particularly for the transfer of the body, and for appropriate communication with the family, constituted an undesirable administrative practice causing severe distress.
The family contended that there was a poor standard of care for Mrs McCarthy in St. Mary's Hospital, including a lack of social/recreational activity for her as a resident of Rhiannon ward. It was also contended that standards of care related to her personal hygiene were poor.
The investigation of this complaint took place against the background of a new standards framework for nursing homes in Ireland. In February 2009, the Health Information and Quality Authority (HIQA) published National Quality Standards for Residential Care Settings for Older People in Ireland (the Standards). The purpose of the Standards, which are underpinned by the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2009 (the 2009 Regulations) is to promote best practice in the residential care of older people. They encompass a broad range of areas, including standards related to rights, protection, health and social care needs, the care environment, and staffing. The standards represent an important tool for ensuring excellence in residential care settings and a useful benchmark against which services can be assessed by staff, recipients of services, and their families and representatives. (Some of the HIQA standards are linked to regulations. Where standards are not based on regulations, they are designed to encourage improvement in service provision (HIQA National Quality Standards for Residential Care Settings for Older People in Ireland 2009).)
Since the complaint in this case was made, a further change has been implemented with regard to inspections of public nursing homes. Whereas previously the HSE was responsible for the inspection of private nursing homes, public facilities were not subject to inspection. This changed with the introduction of the 2009 Regulations, and, since 1 July 2009, all designated centres, including HSE public facilities, of which St. Mary’s is one, are subject to independent inspection by HIQA. The Ombudsman welcomes both of these developments as significant for the protection of the rights of older people living in residential settings. St. Mary’s was inspected by HIQA on 21, 22 and 23 April 2010, and its inspection report was published on 3 February 2011. It is available on HIQA’s website at www.hiqa.ie.
While the HIQA standards were published three months after Mrs McCarthy’s death, they represent what was accepted best practice in the care of older people for the duration of Mrs McCarthy’s time at St. Mary’s (September 2007 to November 2008). HIQA published the standards, in draft form, in August 2007. While the Ombudsman did not rely on the standards, they were a useful point of reference, as representing best practice at the time, in her assessment of the service provided to Mrs McCarthy. The Ombudsman found a precedent for this approach in the 2008 report on St. Mary’s, published by the HSE, where the draft HIQA standards were used to evaluate standards for people in eight areas of St. Mary’s providing long-term residential care (Health Services Executive, Report of the Evaluation of Standards in St. Mary’s Hospital, Phoenix Park, March 2008). The scope of that evaluation included Rhiannon Ward, and Mrs McCarthy was a resident of Rhiannon ward when it took place.
Whereas HIQA inspects residential care homes, and assesses them against the standards, it does not deal with individual complaints. Under the statutory complaints process, the Office of the Ombudsman is the only agency which has authority to examine complaints from individuals in HSE-run facilities, about matters which have affected them directly, when they are not satisfied with the HSE’s response.
As stated above, the Statement of Complaint issued to the HSE on 24 July 2009. The HSE was asked to provide the Ombudsman’s Office with a report on this case, and a copy of all records related to Mrs McCarthy’s care, along with various policy documents. On receipt of the report, records and policy documents, investigators carried out a desktop analysis of their contents.
Interviews with the following people were then held in order to gather further evidence and to seek further information in the case:
Dr. Y, former Medical SHO to Dr. X, was interviewed by telephone as she currently resides in the United States. Nurse D, Clinical Nurse Manager I, was also interviewed by telephone. As well as interviewing personnel involved in Mrs McCarthy’s care, investigators visited Rhiannon Ward in order to familiarise themselves with its layout.
The Ombudsman decided to seek independent, expert, clinical advice in this case. The Office has a service level agreement with the UK Parliamentary and Health Service Ombudsman for the provision of clinical advice, using a panel of experts governed by that Office. Expert advice in this case was provided by a senior nurse with expertise in falls and fractures, and considerable experience in the care of older people. Medical advice was provided by a consultant geriatrician. Both experts were provided with appropriate information on the case. As explained above, the Ombudsman cannot examine actions which in her opinion are taken solely in the exercise of clinical judgement in the diagnosis or care and treatment of a person. The Ombudsman’s request for advice was made purely to be fully informed on the issues relevant to this investigation.
(The UK Parliamentary and Health Service Ombudsman reviews approximately 14,000 complaints about the UK health service every year. She has a number of clinicians on her staff. She also contracts independent expert advice from a specially convened panel of experts who are practicing in healthcare. In 2010, the Office of the Ombudsman developed a Memorandum of Understanding and Service Level Agreement with the UK Parliamentary and Health Service Ombudsman, which allows it to obtain medical, nursing, and other relevant clinical advice as required.)
Because of the number of issues involved in this investigation, each is dealt with in a separate chapter. Chapters on particular subject areas are followed by chapters in which cross-cutting issues are dealt with. The chapter headings are as follows:
Within each chapter, the information is organised in the following way:
The Ombudsman Act 1980 provides that the Ombudsman shall not make a finding or criticism adverse to a person without having first given the person an opportunity to make representations in relation to it. Accordingly, some individuals who were mentioned in the first draft of this report were provided with relevant extracts and given an opportunity to respond. Responses were received from Nurse A, then Director of Nursing, Dr. X, Consultant Geriatrician, Dr. A, Dr. Y, Nurse H, and Nurse F. Where appropriate, for example, where new information was brought to our attention, changes were made. Some comments were also incorporated, as appropriate.
A draft Investigation report was sent to the HSE on 7 March 2011, and a response was received on 29 April 2011. Reference is made to the HSE response, as appropriate.
As stated in the introduction, on admission to St. Mary’s Hospital, Mrs McCarthy was eighty-one years old and suffered from advanced Alzheimer’s disease. She was assessed as being at high risk of falling. She had a tendency to move about constantly, thus increasing this risk, however her family was reluctant to have her restrained either physically or with medication.
Intrinsic and extrinsic risks for falls and fractures have been identified (HSE - Strategy to Prevent Falls in Ireland's Ageing Population: Report of the National Steering Group on the Prevention of falls in Older People and the Prevention and Management of Osteoporosis throughout Life, 2008.) Mrs McCarthy had many of these risk factors, including: a history of falls; gait and balance deficits; cognitive impairment; being over 80 years old; living in an institutional setting (limited activity) and polypharmacy (being on multiple medications).
The records show that staff were very aware of Mrs McCarthy’s risk of falling, and that interventions were made to modify the risk, such as providing her with an ultra-low bed, moving furniture near her bed and referrals to physiotherapy for assessment. She was also provided with a Poesy alarm to alert staff when she got out of her chair, and hip protectors were recommended, although Mrs McCarthy did not like to wear them and they were not always available on the ward.
St. Mary’s Hospital had a Falls Prevention Policy (Nursing) in place at the time of Mrs McCarthy’s stay (attached at Appendix 2. It is dated effective from 15 September 2005, and for review in January 2006. A reviewed multidisciplinary policy was approved in August 2009. As well as raising awareness of ‘techniques to reduce the risk of falls’, a stated aim of the policy in place at the time of Mrs McCarthy’s stay, was to ‘prevent further falls in persons who have had a fall either before or after admission to the hospital’. The stated objective was to ‘ensure a comprehensive assessment is completed and interventions are put in place to minimise the risk of falls’. The policy noted that ‘people with dementia or acquired brain injuries are especially vulnerable regardless of their age’.
The policy provided for the completion of a Falls Risk Assessment Chart on admission (see Appendix 2). The assessment tool was devised by St. Mary’s Hospital and showed scores between 0-24 points as indicating low risk for falls, while scores over 25 indicated high risk. A high score (>25) indicated that ‘the patient/resident is at a high risk of sustaining a fall or falling again’. In such cases the policy provided that the nurse would initiate the hospital’s Falls Risk Reduction Care Plan and implement measures to reduce the risk of further falls. The policy stated that Care Plans should be reviewed every six months, and that the patient should be reassessed monthly.
When Mrs McCarthy was assessed on admission (7 June 2007), she had a score of 40. A further assessment dated 16 August 2008, showed a score of 65. The Ombudsman was informed by the hospital that the maximum score was 75 (although, from the form used, the method by which this is computed remains unclear). The Office was told by the Hospital that a new form is in use since 2010.
At the time of Mrs McCarthy’s stay, there were twenty eight patients on Rhiannon Ward. In its initial submission the hospital informed this Office that the staffing level for the ward during the day was four registered nurses and three healthcare assistants in the morning (a total of seven staff); and three registered nurses and three healthcare assistants in the afternoon (a total of six staff). There was also a member of household staff on duty from 08.00 to 18.00. In her submission dated January 2011, in response to draft extracts of the Ombudsman’s report, the then Director of Nursing said that for the period from 20.15 to 20.45, there are four nurses and one healthcare assistant on duty. At 20.45 night duty staffing of one registered nurse and one healthcare assistant commences and is in place until 07.45 the next morning. There is one extra nurse and one extra healthcare assistant available as relief staff for the night shift for the entire hospital.
Rhiannon Ward operated a system of ‘care pairs’ during the day, whereby one nurse and one healthcare assistant had responsibility for a group of residents (residents were divided into three groups: 9, 9, and 10). The fourth registered nurse was usually a Clinical Nurse Manager and acted as supervisor of the three teams. Residents slept in six rooms located off a central corridor.
As stated in the introduction, Mrs McCarthy had five falls (two un-witnessed) in the four months prior to her death (on 27 July 2008, 2 November 2008, 17 November 2008, 22 November 2008, and 23 November 2008). On 28 September 2008, there was an un-witnessed incident when she was found in bed with a bleeding wound on her forehead and a laceration to her forearm. The family was particularly concerned about the un-witnessed events, and distressed by the fact that their mother fell twice in eight hours (on 22 and 23 November, 2008), only days after the fractured pubic rami was discovered. They sought an explanation as to why Mrs McCarthy was not provided with a one-to-one carer (a ‘special),particularly for the period following the fall, on 17 November 2008, in which she sustained the fractured pubic rami, that is, in the week prior to her death. They claimed that she was not adequately supervised.
In their letter of complaint the family also claimed that the hospital failed to X-ray Mrs McCarthy in a timely manner following the fall of 17 November 2008, and queried why she was taken out of bed on 21 November 2008, when the doctor had ordered bed rest.
The relevant part of the Statement of Complaint which was sent to the HSE states:
"Mrs McCarthy sustained several falls in the weeks and days prior to her death. Her injuries included a fractured pelvic bone and a broken nose. The complainant contends that the number of falls sustained, and resulting injury, was due to inadequate steps having been taken to prevent falls, and to inadequate supervision of Mrs McCarthy and poor management of her condition. The Death Notification Form for Mrs McCarthy shows pneumonia as the cause of death, with antecedent cause listed as 'fracture of the left pubic rami due to or as a consequence of a fall".
In his written submission to the Ombudsman’s Office, Dr. X, the Consultant Geriatrician responsible for Mrs McCarthy’s care, stated his opinion that her risk of falling remained high despite efforts to modify it. He stated that her history of “advanced cognitive impairment was the principal determinant and predisposing risk factor to the falls she sustained in the later part of her illness’’. He also stated that given the combination of factors in the case, “no specific set of interventions could definitively have been put in place that would guarantee that Mrs McCarthy would not sustain a future fall”. He drew attention to the wishes of Mrs McCarthy’s family that their mother would not be sedated and the resulting lack of a curb on her tendency to get out of bed unsupervised. He stated “Falls and fractures (and the infective illnesses such as pneumonia that can occur in their aftermath), can commonly complicate the later stages of dementia.”
In relation to the falls sustained on 22 and 23 November 2008, he stated
“... family have expressed concern as to why their mother had a number of falls ... within 12 hours. My own impression having not examined her on the date is that at this stage she was developing a delirium secondary to an emerging lower respiratory tract infection and hence had a greater degree of behavioural and psychological symptoms than usual ... In the setting of advanced chronic cognitive impairment, patients often manifest an emerging physical complaint (such as infection) with a worsening of their cognitive profile, falls, or worsening mobility.’’
“... in the context of making a decision about the relative benefits and harm from interventions to prevent a future fall, especially with regard to Mrs McCarthy’s clinical characteristics, there is usually no ‘right or wrong’ method. In my view any possible reasonable steps that were available were taken to prevent Mrs McCarthy from falling and her family’s concerns about the use of behaviour modifying medication was respected.”
The hospital claimed that all reasonable steps were taken to prevent falls in Mrs McCarthy’s case. In its submission, by the then Director of Nursing, it pointed to the fact that Mrs McCarthy’s physical and psychological condition was complex and that, in accordance with the family’s wishes, chemical and physical constraints were not used – “Her dementia was such that she had good physical functioning while at the same time did not have any safety awareness to limit falling.”
Regarding the adequacy of supervision, the Hospital claimed that Mrs McCarthy received “as much staff supervision as possible and when required especially during periods where Mrs McCarthy was very agitated”. It is stated “In the last two days of her life a Healthcare Assistant was assigned to ‘special’ Mrs McCarthy to ensure her safety during the day”.
The Hospital stated that one-to-one supervision of Mrs McCarthy was not possible on an on-going basis. It said that the financial impact of providing her with a special carer would have been prohibitive, especially in circumstances where other patients required the same level of care.
Because Mrs McCarthy’s family had particular concerns about the falls sustained by their mother in the weeks prior to her death, those falls, and the incident of 28 September 2008, when she sustained an injury, were examined in detail. This included a detailed examination of the relevant records, and interviews with staff involved in her care. The evidence gathered on all matters related to falls management for Mrs McCarthy is set out in this section, and is analysed in the section which follows.
This incident was of particular concern to the family because of the injury sustained, and, more particularly, because it was not witnessed by hospital staff. The nursing notes show that at approximately 09.20 Mrs McCarthy was found, in her bed, bleeding from a wound on her forehead. Nursing staff did not know how Mrs McCarthy sustained her injury. The medical notes for that day state that Mrs McCarthy had one laceration on her forehead and pulled skin over her left forearm. The family could not understand how their mother had injured herself, and made her way back to her bed, bleeding from a wound, without having been seen by nursing staff.
The nurse assigned to Mrs McCarthy’s care on this date, Staff Nurse H, wrote in the nursing notes that Mrs McCarthy was found at around 09.20 with a bleeding wound. Blood was noticed on her pillow, and, on examination, she was found to have an injured right eye and a cut near her eyebrow. In the hospital’s submission to the Office, the Director of Nursing stated that the patient had been lying on her right side with the result that the injury could not be seen. The submission stated that blood was then noticed near Mrs McCarthy’s bed and a healthcare assistant noticed blood at the nurses’ station when her uniform was stained by leaning against it. The office was told that nursing staff surmised that Mrs McCarthy hit her head on her way to the toilet and returned to bed without being noticed. They estimated that this happened sometime between 08.50 and 09.10 which is a very busy time on the ward as people are being given morning care. The Clinical Nurse Manager said that at the time of this and later falls there was a highly dependent woman in a side room on the ward and that it took 10-15 minutes to get her out of bed. It is thought that the staff assigned to Mrs McCarthy were working in a side room with that patient at the time that this incident occurred. The side room was some distance from Mrs McCarthy’s room and the Office was told that it would not have been possible for staff to see or hear Mrs McCarthy from it if she fell.
The medical notes show that Mrs McCarthy was reviewed by the doctor on duty at 09.30, and again at 21.15. The doctor noted that it was not possible to obtain information about the fall from Mrs McCarthy (due to her inability to communicate). She was reviewed again the next day when the doctor noted her unsteady gait (“+++ unsteady gait”). A brain scan was ordered which showed no injury and the doctor requested ‘close observation with regard to safety’. The doctor also spoke to family members, who, she noted, were upset that nobody had noticed what had happened. She apologised to the family for this.
The family also queried their mother’s treatment after a fall sustained on 17November 2008. They questioned the delay in having their mother x-rayed and claimed that the X-ray taken on 19 November 2008, which showed a fractured pubic rami, was taken only at their insistence.
The nursing notes show that at 03.15hrs Mrs McCarthy was seen by nursing staff walking quickly along the corridor having previously been asleep in bed. She was then seen to fall into a sitting position beside a food trolley. She had small abrasions to her left arm but had no apparent pain. She was reassured and returned to bed where she settled back to sleep. Nurse G noted the next morning that Mrs McCarthy was complaining of pain over her left leg and was limping while walking. The notes state that she was very agitated and tried to walk around the ward, even with the pain in her leg, and had a ‘very unsteady gait’. The notes also show that she was caught nearly falling again but that kitchen staff stopped her. They say that healthcare staff were left with her "almost at all times’’ and that she was “very difficult to manage due to agitation”.
Dr. M. reviewed Mrs McCarthy at 13.00hrs. He found that there was no evidence of pain, that she could weight bear and walk with assistance. The medical notes show that he prescribed analgesia as required and said that Mrs McCarthy was to be observed for pain. When interviewed, Dr. M could not remember having been asked by the family to arrange for an x-ray. There is no nursing note for 18 November 2008, despite the fact that the patient was to have been observed for pain, and she was not reviewed by Dr. M on that day. On 19 November, a note by the Infection Control nurse, (there was a suspected case of noro virus on the ward) states that “medical and nursing staff have assessed patient’sx-ray as absolutely necessary” and that Dr. M ordered that both Mrs McCarthy’s hips be x-rayed.
The x-ray result, reported to nursing staff that afternoon, showed “fractures involving the left superior and inferior pubic rami the overall positions of which appearsatisfactory”. Dr. M saw the patient at 10.30 am the next day (20 November 2008) and ordered bed rest and analgesia as required.
In her interview with investigators, Nurse C, CNM11, said that there was an outbreak of the noro virus on the ward at this time. She explained that both herself and Dr. M assessed the patient and considered that the pain was most likely due to soft tissue damage. She explained that it can be traumatic for a dementia patient to be x-rayed, and they did not want to do that unnecessarily. She was not on duty the next day, but told investigators that it was her understanding that the patient’s mobility subsequently disimproved, and that the x-ray was then considered necessary.
The nursing notes show that on 22 November 2008, Mrs McCarthy was sitting in a chair in the early evening and later was in bed. At 20.00hrs it is noted that she tried to leave her bed “many times’’ to walk. The nurse on duty, Nurse E, then placed her in a wheelchair “to prevent fall’’. In an interview with investigators, the nurse on night duty, Nurse F, said that Mrs McCarthy was seated on the corridor for close observation so that she could be seen, at a glance, when the nurse was attending to other patients in rooms off the central corridor. At 21.30hrs Nurse F found Mrs McCarthy on the floor. Nurse F had been in a side room with another patient when Mrs McCarthy fell. As she had no apparent injury, Mrs McCarthy was settled back to bed and monitored every fifteen minutes.
At 05.45hrs, on 23 November 2008, Mrs McCarthy was found on the floor in the middle of her room. The fall was not witnessed. Nurse F informed the doctor on call. Mrs McCarthy was then placed in a wheelchair for one-to one observation and taken by Nurse F and the healthcare assistant on their ward round. In an interview with this Office, Nurse F said that she was afraid to leave Mrs McCarthy in her bed as she was awake and agitated and she was concerned that she might fall again if she was left alone. In response to extracts from the Ombudsman’s draft report, she reiterated that she felt she had no alternative but to take Mrs McCarthy with her for close observation to ensure her safety. She said that she had reported the two falls to the Night Supervisor who monitors night duty (including monitoring whether resources are adequate) and assigns relief staff as appropriate. She said that whereas she was aware that the hospital had a relief nurse at night, she did not specifically ask for that person to be sent to Rhiannon as she was aware that that person provided relief to the entire hospital and could have been with another patient. Nurse F said that she did not see any injury to Mrs McCarthy’s face before the end of her shift, and Nurse E did not note an injury when she received the care of Mrs McCarthy at 08.00hrs, in a wheelchair, on the corridor. Subsequently, at 08.30hrs, it is noted that Mrs McCarthy was found to be bleeding from her nose.
St. Mary’s Falls Prevention Policy is described at 2.1.2 above. Two Falls Risk Assessment Charts were completed for Mrs McCarthy, one on admission in June 2007, which showed that she had a score of 40 points out of a possible total of 75, and one on 16 August 2008, which showed a score of 65. Under the policy, a score greater than 25 meant that the patient was considered to be at high risk of falling. In fact, the scores for Mrs McCarthy were described to the Ombudsman’s Office, by the hospital, as ‘extremely high scores’.
In accordance with the policy, a score greater than 25 should initiate a Falls Risk Reduction Care Plan. The policy states that for patients in the high risk category, the Care Plan should be reviewed every six months. Whereas two such falls care plans were provided for Mrs McCarthy, there should have been at least three for her period at St. Mary’s (one each for June 07; December 07 and June 08). Neither of the plans provided was dated, nor was there a place on the printed form in which to enter a date.
The policy also states that patients in the high risk category should be assessed monthly and immediately following a fall. There is no record of monthly reassessments having taken place, nor was Mrs McCarthy reassessed formally following falls in accordance with the Policy. From the documentation provided by St. Mary’s, fourteen months appear to have elapsed between formal falls risk assessments. I am told that at the time Mrs McCarthy was resident reassessments were recorded using the Falls Risk Assessment Chart as there was no specific form for reassessment. I understand that, under a revised policy, a specific reassessment form is now in use.
The Falls Risk Reduction Care Plan included a check-list of interventions for the patient, some of which, such as referral to the Physiotherapy Department, and Occupational Therapy Department, should have shown the date on which the referral was made and the name of the referring health professional. Neither dates of referral nor names of the referring person were entered on Mrs McCarthy’s falls care plans. Both indicate that she was referred to the Physiotherapy Department for a footwear assessment, and one shows that there was a referral to Occupational Therapy for a seating assessment.
The Hospital's falls policy states that 'all falls and near misses must be documented on the Falls Monitor Record’ which includes provision for the time the fall occurred and a description of the fall. Documentation for Mrs McCarthy shows a total of two falls (12 May 2008 and 27 July 2008) for the duration of her stay. Incident report forms, combined with medical and nursing notes, show that she is recorded as having fallen a total of five times between 27 July and 23 November 2008. Despite this, only one fall is shown on the Falls Monitor Record for the period.
The staffing level for the ward is set out at 2.1.3 above. For the day shift, the ward had three ‘care pairs’ of one staff nurse and one healthcare assistant, with one extra nurse in the morning. There was one staff nurse and one healthcare assistant on the night shift. In her interview with investigators the CNM II said that of the twenty-eight women on Rhiannon Ward, approximately twenty would have been in the advanced stages of dementia. Three of Mrs McCarthy’s falls – those of 17, 22, and 23 November, occurred during night duty when there was one nurse and one healthcare assistant to look after twenty-eight patients distributed across six rooms. The CNMII told investigators that when Mrs McCarthy fell, staff were attending to other patients. From the side rooms on the ward, staff were unable to see, or hear, other patients.
Investigators noted from the records that on one particular night, Mrs McCarthy had had extra supervision. Nurse C explained that on a small number of occasions, Mrs McCarthy had been assigned one of the relief staff until she settled. Nurse C stated that this level of assistance would be useful every night, but that this was not possible due to staffing restrictions.
Regarding the employment of one-to-one ‘special’ nurses for patients at risk, Nurse C explained that such nurses, when they are sanctioned, are agency nurses because the hospital does not have sufficient staff to provide them. These agency nurses are not necessarily trained in dementia, and often come from a different cultural background to the patient. She said that for these reasons, patients can have difficulty relating to them.
The nursing notes show that on a number of occasions from July 2008 onwards, Mrs McCarthy was assessed by nursing staff as needing constant supervision. For example, on 30 September, following the fall of the previous day, it was noted “Mary has poor safety awareness and is a very high risk of injuring herself. Requires constant supervision.This is not always possible as Mary currently has not one-to-one”. On 7 October, the notes state “needs special one to one care”. On 21 November, following the x-ray result which showed the fractured pubic rami, the notes show that Mrs McCarthy’s poor safety awareness and risk was explained to her family by both Dr. X and Nurse C.
The former Director of Nursing was asked whether, in her view, it might have been appropriate to assign a special carer to Mrs McCarthy given her history and the pattern of falls that was emerging. She replied that whereas it might have been desirable, many people in the hospital would have had a similar level of need, and it would not have been possible to provide specials to all of them as the cost was not "achievable or sustainable’’. When asked why Mrs McCarthy was not allocated a special carer following the fall on 17 November, given her susceptibility and injury, she stated “well again I would have to say to you that if that had been the case then we would have many, many specials inthe hospital ...” She pointed out that Mrs McCarthy was assigned a ‘special’ on 23 November when it was ordered by the doctor on call.
When asked about the mechanism to assign ‘special’ carers to patients, the Director of Nursing explained that it was the medical staff who ordered them. Following such an order, the Nursing Administration section was asked to provide someone. She explained that Nursing Administration would then look at the request. She said that they would ‘takeseriously that the doctor has prescribed it” as being required for the patient, and “in the main we would get the special for the person or look at alternate ways’. The former Director of Nursing later clarified, in her submission dated January 2011, in response to extracts from the draft report, that any alternatives would be discussed with the relevant doctor.
On the question of whether a special carer should have been assigned to Mrs McCarthy, Nurse C said in her interview that there were patients in the hospital who had one-to-one care but that there was no noticeable change in care that would justify the cost. She felt that if staff were available who were trained in dementia, such care could be very therapeutic. However it was her view that, because of her condition, Mrs McCarthy was at very high risk of falling even if there was someone there at all times. She mentioned cost as a factor in considering the value of a special nurse, but stated that, in Mrs McCarthy’s case, she did not think that this would have prevented her from falling.
Staff Nurse H had recorded in the nursing notes that Mrs McCarthy needed one-to-one care. In her interview, she stated that if a special nurse was considered necessary, nursing staff asked the Clinical Nurse Manager first and then a doctor or the multidisciplinary team was asked to assess the patient, following which a request would be made. She said that it was not encouraged as it is very expensive and, as there are many patients with dementia, families would have demanded a ‘special’ for their family member if they had seen another patient in receipt of one-to-one care.
On 21 November 2008, the nursing notes show that Nurse C explained to the family that the only way to prevent falls was restraint. In her interview with investigators, Nurse C explained that Mrs McCarthy was a particularly challenging patient due to her Alzheimer’s disease, her challenging aggressive behaviour, and her tendency to move about. She said that despite her age and illness, she was very strong “she would walk through things, over things; she had banged her face, her arm. She just had no awareness of safety and yet she was so mobile ... so she was challenging in that regard”. These factors meant that Mrs McCarthy was often a risk to herself and others. Restraint was rejected by the family and Nurse C agreed with this. In her interview she said “the family did not want their mother restrained ... what is life if you can’t move around when you want to ... it was about trying to get the balance right. It is not pleasant, but neither is being 100% safe and being tied in a chair. We explained to the family that she was at increasing risk”. The family’s view is that their mother should have been assigned one-to-one care – a ‘special’ at this time. The former Director of Nursing stated, in her submission of January 2011 in response to extracts from the draft report, that the family did not request a special for their mother at that time. In her interview, she explained that it was unusual for a person with Mrs McCarthy’s level of dementia to remain mobile. Her view was that it would have been impossible to guarantee that she wouldn’t fall even with someone at her side at all times. She said that “if you are balancing the right of a person to move around freely with supervision, versus forcing them to stay sitting, you would choose to allow them to move”. She explained that the thinking on restraint is an evolving area of practice but that there are now so many disadvantages to restraint, so many contraindications, that St. Mary’s strives not to use it.
Mrs McCarthy remained in bed on 20 November. On the morning of 21 November, she was taken out of bed by nursing staff and put sitting in a chair. She is described in both the medical and nursing notes as drowsy and sleepy. The notes show that her medication was reviewed by her consultant that day, and that she returned to bed and remained there. In their complaint, the family was concerned that their mother had been taken out of bed when bed rest had been ordered. They told investigators that when they visited their mother that morning they found her drowsy and slumped in a chair beside her bed. In an interview with investigators, the nurse who took Mrs McCarthy out of bed said that she couldn’t remember exactly what had happened that day, but said that, generally, if a patient is mobile, they are taken out of bed to prevent pressure sores. She agreed that the patient was returned to bed at her family’s request and that she stayed there and, unusually for her, was disinclined to get up.
Physiotherapy assessment reports on Mrs McCarthy’s file show that she was assessed on four occasions – 20 June 2007, 3 July 2008, 16 July 2008, and 29 September 2008. At the initial assessment it was decided that she did not need continuous physiotherapy. On the next occasion, twelve months later (3 July 2008), approximately 5 months before her death, she was reviewed at the request of nursing staff due to deterioration in her mobility. The physiotherapist stated that due to her significant cognitive impairment, she ‘would not be a candidate for balance strengthening’ and instead recommended hazard modification. The physiotherapist states in the notes of her assessment that the Clinical Nurse Manager was ‘advised re use of hip protectors, wearing shoes rather than slippers and environmental modification’. She also states that she advised re Posey Alarm (a sensor alarm which sounds when the patient leaves his/her bed or chairJ) and ‘need for restraint policy’. On assessment on 16 July 2008, the physiotherapist’s view was that ‘due to significant cognitive impairment, Parkinsonism symptoms are non-modifiable’. On 29 September 2008, the Physiotherapy Department was again asked to review Mrs McCarthy due to multiple falls. This assessment states that due to the severity of her cognitive impairment, and her inability to follow instructions, it was difficult to assess her accurately. However the physiotherapist found ‘deficits with regard to dynamic balance/ reactions’, ‘shuffling gait pattern’ and ‘poor safety awareness’.
The Ombudsman is aware that there is no definitively proven or widely accepted process to prevent residents in long term care, or those with advanced dementia, from falling, and that even the use of multi- faceted approaches to falls prevention will not prevent some falls from occurring.
There is no way to establish how Mrs McCarthy sustained her injury on the morning of 28 September 2008. Due to her severe cognitive impairment she was not able to tell staff what had happened. The notes show that members of both nursing and medical staff apologised to the family. The notes also show that Mrs McCarthy is recorded as having very poor safety awareness at this time, and that she almost fell again the next day as she tried to find her shoe. In that case, staff saw her and stopped her. Given the staffing profile, and the time of day at which the fall occurred (it is estimated to have occurred between 08.50 and 09.10), it is likely that staff were attending to other patients, possibly in side rooms, when Mrs McCarthy fell. The notes do show that she was reviewed by a doctor within minutes of having been found, and that a brain scan was ordered to assess whether there was any injury. The reviewing doctor also spoke to the family. Nursing staff made a multidisciplinary team (MDT) referral regarding safety, balance and co-ordination and the furniture around Mrs McCarthy’s bed was rearranged to reduce her risk of injuring herself.
The nursing notes show that on 22 November 2008, Mrs McCarthy fell at 21.30. She had no apparent injury, and was put back into bed. The notes also show that an hour and a half earlier, she had been placed in a wheelchair on the corridor so that she could be monitored by Nurse F, the nurse on night duty, while she attended to the other patients in rooms around the ward. Following another fall at 05.45 (23 November 2008) Nurse F decided to keep the patient with her, in a wheelchair, for fear she would fall again. Given the staffing level on the ward, this was not an unreasonable approach to the problem of supervising Mrs McCarthy while attending to the needs of the other patients, and the Office can understand the nurse’s predicament in that regard. However, the Ombudsman has concerns about the impact of this on the privacy and dignity of the other patients. The Ombudsman thinks that the presence of Mrs McCarthy, while other patients were being attended to (albeit outside the curtain as stated by the nurse in her interview), was not appropriate. From Mrs McCarthy’s perspective, it is not acceptable that, rather than remain in her own bed, where she may have settled back to sleep, she was taken with staff as they cared for other residents. Nurse F did explain that Mrs McCarthy was very awake and agitated initially, and unlikely to sleep. She said that later she was in good form and smiling, and had tea and toast with the staff at approximately 07.00hrs.
The evidence shows that the Hospital’s falls prevention policy was not complied with fully. Reassessments did not take place at the standard intervals set down, nor did they take place following falls as set out in the policy. However, there is evidence from the nursing notes that Mrs McCarthy’s risk of falling was assessed, albeit informally, outside the procedures in the policy. For example, it is noted in the nursing notes that Mrs McCarthy was assessed as being at high risk of falling and as having ‘no safety awareness’ (weekly summary note of 5 October 2008).
Mrs McCarthy was referred to the physiotherapist who found on a number of occasions that she was not suitable for physiotherapy. There is evidence that hip protectors were sometimes worn by Mrs McCarthy, but the records show that they were not always available on the ward. The Director of Nursing told investigators that there is conflicting evidence as to whether hip protectors are effective in protecting patients from hip fractures. She also said that Mrs McCarthy did not like wearing them. Mrs McCarthy did have a Poesy alarm at times, but that she tended to remove it herself, so it was not effective. There is no evidence of a referral (apart from a seating referral) to an Occupational Therapist specifically. (Occupational Therapy is also dealt with in Chapter 5, in the context of social and therapeutic recreational activity, and in Chapter 6, Record Keeping).
While there are entries in the narrative notes regarding the management of falls risk and the assessment of the patient’s risk status, they did not, consistently, and on a weekly basis, provide updates on the falls prevention plan for Mrs McCarthy, and the interventions to manage her falls risk, as should have occurred in accordance with the policy. There appears to be no link between these entries, the formal falls risk assessment, and the care plan, as would appear to have been envisaged in the drafting of the policy document. As a result it is difficult to establish, from the records, a coherent and comprehensive picture of the management of Mrs McCarthy’s fall risk and the interventions to reduce it.
Deficits in the falls prevention policy documentation are dealt with in Chapter 6, Record Keeping. The former Director of Nursing stated, in her submission of January 2011, in response to the draft report, “the fact that the completion of forms does not appear optimal does not mean that Mrs McCarthy did not get appropriate interventions and referrals by nursing staff”. She said “I contend that despite minimal areas of noncompliance with policy in completion of the forms, all appropriate interventions were being used”. However, where a policy is in place, and where that policy requires that documentation be completed, it is important to the implementation of the policy that it be completed. If the documentation is considered unnecessary, then the policy should be reviewed and revised.
The HSE accepted, in its response to the Ombudsman’s draft report, that formal reassessments of Mrs McCarthy’s risk of falling were not carried out. The HSE’s response on this matter is in Chapter 7 of this report.
With regard to staffing, the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2009 (the Regulations), state (at Section 16(1)) that the person in charge shall ensure that the numbers of staff and skill mix of staff shall at all times be appropriate to the assessed needs of the residents, and the size and layout of the designated centre. These regulations were not in force when Mrs McCarthy was resident at St. Mary’s. The HIQA Standard for staffing levels and qualifications, Standard 23, introduced in 2009, also states that there must be sufficient staff employed in the residential care setting to ensure continuity of care for residents. The Standard states ‘Agency staff and overtime are only used for unforeseen contingencies such as unexpectedly high levels of sick leave’. Furthermore, the Standard states that the number of staff on duty at night takes into account fire safety requirements to ensure the safety of residents in the event of a fire. Regardless of the fact that the final standards were not published at the time Mrs McCarthy was resident at St. Mary’s, the Office was advised that their content represented best practice at the time. It is a matter for HIQA to assess the staffing level for the ward, and the hospital, against the standard. The Ombudsman interest in looking at staffing levels is limited to examining how it affected Mrs McCarthy’s care, and whether she was adversely affected by an administrative failure in the provision of resources.
Regarding recommended staffing levels, I am advised by the Ombudsman expert nursing advisor (see Chapter 1, Section 1.5) that there is no international consensus on staff to patient ratios. Nor is there, despite several available tools, universal agreement on a tool to measure the staff required for particular wards. The staffing level on Rhiannon ward, particularly on night duty, given its high dependency patient profile, would appear to have been a factor in the later falls which Mrs McCarthy sustained. The physical layout of the ward, which cared for a population with significant needs, was also a factor as it created difficulty for staff in the supervision of patients. When staff worked in a room at one end of the ward, they could neither see, nor hear, patients in some of the other rooms on the ward. As stated above, it is likely that staff responsible for Mrs McCarthy’s care were dealing with other patients when she sustained an injury on 28 September 2008; and on the night of 22 November 2008, and into the morning of 23 November 2008, staff considered it necessary to keep Mrs McCarthy with them on their ward round to ensure her safety. With one staff nurse and one healthcare assistant on duty to look after 27patients, many of whom were high dependency, there was no capacity, within the standard duty for the ward, to have a staff member stay in, or near, Mrs McCarthy’s room to supervise her. (In her submission of January 2011, having seen extracts of the draft report, former Director of Nursing, told the Office that as one resident of Rhiannon ward had died on 18th November, there were 27 and not 28 residents in the last week of November 2008.
There was one relief staff nurse and one relief healthcare assistant on night duty, shared across the entire hospital, however, the nurse on duty on the night of 22 November did not call on this resource. In her submission of January 2011, in response to extracts from the draft report, the former Director of Nursing pointed out that, at night, the hospital is supervised by an Assistant Director of Nursing, and a Clinical Nurse Manager II. She said “the administrative process is that they assess the situation on an on-going basis. They have the capacity to send support and indeed offer support themselves when the need arises”. She said that if extra supervision had been required on Rhiannon ward it could have been prioritised for allocation of the relief staff, or supplementary agency staff.
The HSE’s response on the matter of staffing levels is at Chapter 7 of this report.
The Office was advised by the expert nursing advisor that there is no evidence to show that one-to-one care decreases the risk of falls, and that one-to-one care is not necessarily indicated following a fall. This point was also made by both the Director of Nursing and that Clinical Nurse Manager in their interviews with staff and the Ombudsman accepts the case as made by them. However, the Ombudsman is critical of the failure to consider the need for extra supervision of any kind for Mrs McCarthy at night, particularly during the period following her fall on 17 November. Mrs McCarthy was drowsy and in bed on 20 and 21 November, but as soon as she began to move around again she fell – twice within an eight hour period. As discussed above, the situation which arose following those falls where staff felt it necessary to keep an eighty two year old woman with them, in a wheelchair, in the early hours of the morning, to ensure her safety, was not consistent with standards of privacy and dignity. (HIQA standard 4 deals with the right to privacy and dignity and states that arrangements must be in place to ensure that the resident’s privacy, dignity and modesty are respected at all times.)
Nursing staff considered at times that Mrs McCarthy required one-to-one nursing and entered this in the nursing notes. Indeed, as early as her admission in June 2007, the matter of extra supervision for Mrs McCarthy had been raised. The medical notes on that date contain the following “Note: She needs special minder long term”. The Office was told that on admission Mrs McCarthy was assigned a special nurse on foot of this doctor’s order, and that this was later reviewed and withdrawn when she became more settled. Later the need for extra supervision is noted by nursing staff. On 7 October 2008, for example, nursing staff noted that she needed ‘special one-to one care’. There is no evidence that these assessments of need were formally brought to the attention of senior staff or management for any required action to be taken. From interviews with medical and nursing personnel, it would appear that cost was an important factor in decisions about one-to-one supervision. The former Director of Nursing stated that Mrs McCarthy required close supervision and said that staffing resources were, in the main, able to provide it. In her submission of January 2011, in response to extracts from the draft report, she says that close supervision of Mrs McCarthy did not constitute a requirement for an additional staff member. She said that the term ‘one-to-one’ may indicate heightened supervision within existing resources. She also said that when a clinical judgement was made that a special nurse was required, and when it was ordered by a doctor in accordance with hospital policy, nursing administration provided it. She explained that this happened twice during Mrs McCarthy’s stay, first time on her admission, and the second time on the day before she died. She contested the Ombudsman’s view that consideration should have been given to one-to-one care following the fall on 17 November.
Mrs McCarthy was x-rayed on 19 November 2008, having fallen on 17 November 2008. Following a review of the evidence on this matter, it would appear that the delay in this case was due to clinical judgement about whether an x-ray was required. It would appear that matters such as infection control (due to noro virus) and stress to the patient were considered, alongside the possibility that the pain which was evident was due to soft tissue damage. As these matters relate solely to clinical judgement, the Ombudsman is precluded from examining them.
Mrs McCarthy’s family was reluctant to have her restrained in any way and medical and nursing staff at St. Mary’s supported this position as representing best practice in the care of the elderly. While there was no formal restraint policy in place for the majority of Mrs McCarthy’s stay, a policy on restraint had been developed by the end of 2008.
Regarding the matter of bed rest, it is clear from the medical notes for 20 November 2008 that bed rest was prescribed by Dr. M and that Mrs McCarthy stayed in bed on that day. In his interview, Dr. M explained that following his order of bed rest, he would have expected Mrs McCarthy to have remained in bed for a couple of days. He did not write the duration of bed rest in the medical notes. Nurse H, who got Mrs McCarthy out of bed on 21 November, did not remember, when interviewed, exactly what had happened. However she explained that, in general, if patients are mobile they are taken out of bed ‘for their skin integrity ... and to prevent pressure sores’. She did record in the nursing notes that Mrs McCarthy was very sleepy and drowsy and that, when returned to bed, she did not try to get out again.
In her submission to the Office, dated 24 January 2011, in response to extracts from the draft report, Nurse H explained that prolonged bed rest, particularly four days after a minor fracture, would have been more detrimental than beneficial to Mrs McCarthy’s health and wellbeing. She pointed out that Dr. M did not specify the duration of bed rest in his note, and that he had written that there was “no evidence of displacement” [of the bones]. She said that, in the handover at the start of the day, at which patients were discussed, the nursing team would have agreed that Mrs McCarthy could sit out in a chair for a couple of hours if she was able. Nurse H judged that, from a clinical perspective, it would be beneficial for Mrs McCarthy to sit out rather than remain in bed. She also pointed out that both Dr. M and Dr. X reviewed Mrs McCarthy while she was sitting out and did not object to this. Having reviewed her, Dr. X did not continue the order for bed rest.
In its response to the Ombudsman’s draft report, the HSE accepted that formal reassessments of Mrs McCarthy’s falls risk were not carried out. It has stated that the Falls Risk Assessment Sheet has been reviewed and an up-dated version (last reviewed in March 2010) is now in use throughout the hospital. In addition, it advised the Ombudsman that in October 2010, the Falls Multidisciplinary Committee at St. Mary’s produced a booklet entitled “Falls Awareness – Live Life Safely” which provides advice and tips on falls prevention.
In its response to the draft report, the HSE stated that it is its view that the staffing levels on Rhiannon Ward, taking the relief staff into account, were sufficient. It stated that in the absence of a national validated tool, it had reference to Staffing Guidance for Nursing Homes, June 2002, by the UK Regulation and Quality Improvement Authority in formulating its response. It stated “it is worthy of note that the suggested hours on this tool are superseded by the allocation of staff to the Rhiannon Ward in St. Mary’s. The total hours recommended for thirty residents is 102 hours. The total hours allocated to the Rhiannon Ward for 28 residents is 110.7 hours. The Rhiannon Ward is also supported by a strong management function both day and night together with relief staff”. The HSE went goes on to state that staffing levels are a matter of clinical judgement “Staffing levels and specials are a matter of professional clinical judgement having due regard to the individual circumstances of the residents concerned, with regard to their medical diagnosis. In the case of dementia I am advised that the provision of unknown staff can have an adverse effect on the persons concerned”.
The Ombudsman does not accept that staffing levels are entirely a matter of clinical judgment as defined in relation to the Ombudsman’s Office. The Ombudsman considers them to be squarely within the area of administration and management in the support of the clinical function. As stated above, the Ombudsman’s concern in this case was a possible failure in such provision as it affected the care of Mrs McCarthy.
Following the above view from the HSE, investigators again consulted the Ombudsman’s independent expert advisor and requested, in particular, that she look at the UK guidelines and the case made by the HSE in the context of Mrs McCarthy’s profile and that of her fellow residents. While the advice is that the staffing levels on the ward appear reasonable for the morning, afternoon, and evening shifts, the Ombudsman remains concerned about how one registered nurse and one health care assistant could meet the fundamental needs of 28 people on the night shift (20.45 to 07.45) – particularly given the numbers in an advanced stage of dementia. The Ombudsman is advised that there is no guidance or evidence to suggest that fundamental care needs change at night. These factors, combined with the layout of the ward, and the highly dependent patient profile, raise sufficient cause for concern that staffing levels at night are not sufficient to meet the needs of this vulnerable group of patients.
The Ombudsman accepts that the management of Mrs McCarthy’s falls risk presented significant challenges to staff at St. Mary’s. She also accepts that St. Mary’s staff respected Mrs McCarthy’s rights by not using physical or medical restraint to prevent falls. Furthermore, she acknowledge that even multi-faceted approaches to falls management will not prevent falls in someone with the late Mrs McCarthy’s profile. However, the Ombudsman is critical of some aspects of Mrs M’s care in this area, and she finds the following:
Whereas there is some evidence in the records of informal assessment outside the procedures of the hospital’s Falls Prevention Policy, the Ombudsman finds that the policy was not complied with fully due to the failure to carry out formal reassessments of Mrs McCarthy’s falls risk, as provided for. In terms of section 4(2)(b) of the Ombudsman Act 1980, the Ombudsman finds that this is an undesirable administrative practice (4(2)(a)(vi)), and contrary to fair or sound administration (4(2)(a)(vii)).
The staffing level and patient profile of Rhiannon ward has been outlined. Given that Mrs McCarthy had sustained an injury on 17 November, and considering her tendency to move about with an unsteady gait, the Ombudsman finds that, on these grounds, consideration should have been given to the provision of extra supervision for her. The Ombudsman finds that the failure to formally consider any such provision within a system for doing so, based on assessment of her need was based on financial considerations, along with perceived difficulty in obtaining suitably qualified staff. The Ombudsman finds that this is an undesirable administrative practice (4(2)(a)(vi)), and contrary to fair or sound administration (4(2)(a)(vii)).
Given the layout of Rhiannon ward and the highly dependent patient profile, the Ombudsman is concerned about staffing levels, particularly at night. However, staffing levels generally are a matter for HIQA, accordingly the Ombudsman intends to notify HIQA of her concerns in this regard. The Ombudsman is not reassured by the case made by the HSE on this matter in response to her draft report.
As the decision to sit Mrs McCarthy out in a chair on 21 November, was based on a clinical judgement, and the Ombudsman is precluded from examining matters related solely to clinical judgement, she can make no finding on this matter.
As the Ombudsman is precluded from examining matters related solely to clinical judgement, she makes no finding on this matter.
There are two types of post-mortem; Coroner’s post-mortems and Hospital post-mortems. In certain circumstances there is a legal obligation to report a death to the Coroner and it is the Coroner who will establish the cause of death and issue a death certificate. For example, deaths resulting from industrial accidents; deaths which are the result of a surgical or medical treatment or procedure; or deaths connected with crime. Other examples of circumstances where a death must be notified to the Coroner’s office are deaths in any public or private institution for the care of elderly or infirm persons; sudden, unexpected or unexplained deaths; and deaths due, directly or indirectly, to unnatural causes (regardless of the length of time between injury and death), including fractures in the elderly. Once the Coroner has been notified, he or she will decide whether a post-mortem is necessary.
Hospital post-mortems are generally carried out where a patient has died in hospital, at the request of medical staff, when they think it would be useful for research purposes or for the medical care of other family members. In some cases they are carried out at the request of the family. Such post-mortems, completed with the consent of the family, are dealt with under the post-mortem policy of the relevant hospital and are carried out by the hospitals’ pathologists. Following the post-mortem, the post-mortem report is sent to the consultant who was responsible for the care of the deceased prior to his or her death. Families may obtain information on the post-mortem findings from that person.
The Ombudsman is aware that the HSE has developed draft national guidelines on procedures for post-mortems and she welcomes this.
On the day of her death (24 November 2008), Mrs McCarthy’s daughters were not told of their mother’s rapidly deteriorating condition. They had been told, on 21 November, in a meeting with Dr. X, Consultant Geriatrician, and Nurse C, CNMII, that her condition had deteriorated, resulting in further diminished safety awareness. During interviews, both medical and nursing staff agreed that, despite Mrs McCarthy’s pre-existing health conditions, her death was relatively sudden and unexpected. Her family said that when they had asked, on the morning of her death, whether their mother had pneumonia; they were told that she did not, that she had a chest infection. However, when they received a copy of the death notification certificate, it showed the cause of deathas “Bronco-pneumonia” of 2 days’ duration. (Defined on the form as "Disease or condition directly leading to death: This does not mean the mode of dying, e.g. heart failure, asthensis etc. It means the disease which caused death". The form gives “Antecedent causes” as “Fracture of left pubic rami due to or as a consequence of fall” which is shown as having occurred 10 days prior to death). Because of the unexpected nature of her death, and because they were concerned about the effect recent falls and injuries had had on their mother, the family members say that they requested that a post-mortem be carried out. They also agreed, having had it suggested to them, to donate their mother’s brain for research purposes to the newly-opened Brain Bank at Beaumont Hospital. (The Dublin Brain Bank was officially opened in October 2008 at Beaumont Hospital. It is described at section 3.3.4.)
It was the understanding of Mrs McCarthy’s family, and of the staff at St. Mary’s, that Dr. X, Consultant Geriatrician, was making arrangements for the post-mortem and brain donation to take place at Beaumont Hospital. On 25 November 2008 (the day after her mother’s death) Mrs McCarthy’s daughter signed the consent form for both the post-mortem and the brain donation. She understood that her mother’s remains would be taken to Beaumont Hospital later that day, and that the post-mortem and brain donation would take place the following day (26 November).
In the event, neither post-mortem procedure took place. They were cancelled following a phone call to Mrs McCarthy’s daughter at approximately 19.00hrs on 25 November which she found distressing. It transpired, on investigation by this Office, that the phone call (dealt with further in Chapter 4: Communication) was the result of confusion, on the part of Beaumont Hospital, regarding the logistics for the brain donation. Following this call, during which the family realised that Mrs McCarthy’s body had not been moved to Beaumont Hospital, but was still in the mortuary at St. Mary’s, they cancelled the post-mortem and brain donation. They had thought that the body would have been moved that day and were distressed that this had not happened.
The statement of complaint in this case states:
… it is contended that poor and inappropriate communication by the hospital with the family, related to their donation of brain tissue to Beaumont Hospital, caused them serious distress and ultimately resulted in the withdrawal of their consent for a post-mortem which they had originally requested.
It is contended that the absence of protocols for the donation of brain tissue to the Brain Bank at Beaumont Hospital, particularly as regards the transfer of the body, and appropriate communication with the family, constituted an undesirable administrative practice causing severe distress to Mrs McCarthy's family.
With regard to the second point above, once this investigation commenced it became apparent that the Brain Bank at Beaumont Hospital had well established protocols for consent, transfer of the remains, and communication. However, these were not invoked in this case. In examining the cancellation of the post-mortem and brain donation, the reasons for this were examined, along with the issues below:
In its submission, the HSE said that Dr. X undertook to arrange the post-mortem at Beaumont Hospital, at the request of the family, and that St. Mary’s Hospital understood that arrangements for the transfer of Mrs McCarthy’s remains would be made by Beaumont. That submission states that the remains were due to be transferred to Beaumont on 26 November 2008 – two days after her death.
The submission goes on to say that Dr. X was told, on the evening of 25 November, that it was necessary to have Mrs McCarthy’s remains refrigerated due to the fact that brain tissue was to be donated. In his interview, Dr. X said that he was contacted by a member of the mortuary staff at Beaumont Hospital and told about the necessity to refrigerate the remains. This information was later found to be incorrect. As he knew there was no such facility at St. Mary’s, Dr. X phoned the then Assistant Director of Nursing, (now retired), and asked her if she could make the arrangements for the transfer to Beaumont. It was at this point that the Assistant Director of Nursing phoned Mrs McCarthy’s daughter. The HSE submission states that she was upset that her mother’s remains were still at St. Mary’s, but gave the name of the family’s undertaker to the Assistant Director of Nursing. The undertaker subsequently phoned the Assistant Director of Nursing and told her that the family no longer wished to proceed with the post- mortem and brain donation.
In both the HSE submission, and in a submission received directly from Dr. X on the matter, he apologised for the distress caused to the family by actions taken on foot of the incorrect information regarding the requirement for refrigeration which he said should not have occurred.
The HSE also responded to the matter of consent to the donation of brain tissue as the Ombudsman’s Office had pointed out that, whereas consent had been obtained for the post-mortem, a further consent form should have been signed in respect of the donation. The HSE said it would have been necessary to obtain written consent and that this would have happened at a later stage, but it did not happen because the family withdrew their consent for brain banking before the body was transferred to Beaumont Hospital.
Dr. M, Senior House Office, St. Mary’s, wrote in the medical notes on 25 November 2008, that he had notified Dr. X of Mrs McCarthy’s death. He noted that the cause of death was pneumonia, and wrote “in view of recent fall and fracture of pelvic rami, to discuss with the Coroner”. Dr. M’s notes show that he contacted the Coroner’s Office and “discussed the background to the recent events”.
There is nothing in the notes to show that the Coroner was informed that Mrs McCarthy had had two falls in the previous 48 hours, one of which involved a head injury (medical notes of 23 November, and incident report form for the same date refer); or that he was told that the initial result of the x-ray taken on 24 November showed, as noted by Dr.M on that date, “a possible nasal bone fracture but no obvious displacement laterally”. The x-ray was formally reported on 25 November, and shows that there was a fine fracture in the nasal bones but no evidence of displacement. In his interview with investigators, Dr. M said that he could not recall whether he had mentioned the nasal bone fracture to the Coroner’s Office.
It is entirely a matter for the Coroner’s office, an independent office, to decide whether a post-mortem is required or not, on the basis of the information provided to it. The Ombudsman is charged with examining the administrative actions of public bodies. In this case Ombudsman staff examined whether the proper procedure was followed with regard to the notification, including whether all relevant information was provided. The Ombudsman sought information from Dr. Brian Farrell, Dublin City Coroner, about what he had been told in this case. A copy of the record made of the conversation between an official at the Coroner’s Office and Dr. M, was not obtained, however, investigators were told by that Office, in a telephone conversation, that while information was received about Mrs McCarthy’s fractured pelvic bone (which occurred on 17 November, seven days prior to her death), no information was received at the Coroner's Office about her fractured nasal bone.
St Mary’s told the Office that a request for a post-mortem was unprecedented, and that whereas there were procedures in place to be followed for a Coroner’s post-mortem, there were none for hospital post-mortems. St. Mary’s does not have the facilities to carry out a hospital post-mortem, it is not a hospital per se, and does not have a pathologist. Accordingly, other than Coroner’s post-mortems, it did not see itself as being in a position to accede to such a request. When a Coroner’s post-mortem is required, arrangements for the transfer of the remains are made by the Coroner’s Office using the services of a firm of undertakers. St. Mary’s had no arrangement in place for the transfer of remains to another hospital, as the matter of a hospital post-mortem had not arisen previously. Staff of the hospital understood that Dr. X had agreed to arrange a hospital post-mortem at Beaumont Hospital when requested to do so by the family.
In order to establish the procedure for hospital post-mortems at Beaumont Hospital, investigators met with Professor L., Consultant Pathologist. She explained that in cases where the treating consultant decides that a post-mortem would be beneficial, consent is obtained from the next-of-kin and the pathologist is notified. She said that before a hospital post-mortem can proceed, it must be accepted by the pathologist. Internal hospital documentation on the procedure (Doc. No. LP-PM-Autopsy, Revision Date 9/10/2009), provided by Professor L., states:
A clinical consultant may request a PM if he/she is satisfied that the death is not reportable to the Coroner ... .
It goes on to state:
A member of the clinical team must obtain permission for a Hospital PM, ensure that the autopsy consent form (LAB358A) is correctly filled out and that it is brought down to the mortuary immediately, and the case is discussed with the relevant pathologist.
It was the understanding of the family, as well as of Dr. M, SHO, the Director of Nursing, and the nursing staff at St. Mary’s, that Dr. X had agreed to arrange a hospital post-mortem, that is, a general autopsy, on Mrs McCarthy’s body. Dr. M medical notes for 25 November show that he contacted Dr. X to inform him of Mrs McCarthy’s death, and was told to talk to the Coroner. A further note says that the Coroner’s was satisfied that Dr. M could certify the cause of death without a Coroner’s post-mortem. A later note, (at 10.10am) states that Dr. M contacted Mrs McCarthy’s daughter to inform her of this, but that she said the family wanted a post-mortem. It then says ‘contacted Dr. X about the family request. He will organise a hospital post-mortem in Beaumont Hospital’.
Dr. X, in his interview, discussed the matter of a post-mortem and said that this was the first request which he had received, out of approximately thirty deaths each year, since he starting work at St. Mary's in 2004/2005. He also explained that his then Senior House Officer (SHO), at Beaumont Hospital, Dr. Y, who had previously worked in neuropathology, overheard his telephone conversation with Dr. M and that she had suggested that, as Mrs McCarthy had suffered from Alzheimer’s disease, the family might be asked to consider donating brain tissue to the newly-opened Brain Bank.
In his interview Dr. X said that his understanding was that Dr. Y was going to organise the post-mortem, and that mortuary staff at Beaumont would arrange for the transportation of Mrs McCarthy’s remains from St. Mary’s Hospital to Beaumont Hospital. Dr. Y sent an autopsy consent form (LAB358A), by fax, from Beaumont to St. Mary’s on 25 November at 13.09. Mrs McCarthy’s daughter went to the hospital shortly afterwards for the purposes of signing the form. She annotated the form to say that she consented to the retention of her mother’s brain “for the brain bank”. Dr. M has been asked to inform the Ombudsman as to what happened the consent form, that is, did he fax it to Beaumont Hospital, and, if so, to what person, Department, or number. Despite several requests to Dr. M to provide this information, at the time of writing he has not responded to the Ombudsman’s Office. There was no record on the medical file of the consent form having been returned to Beaumont Hospital, and Nursing Administration at St. Mary’s were not able to find any record of its transmission or posting.
Nurse Nurse D, CNM1, told investigators that she was on duty on Rhiannon ward on 25 November and had been present when Dr. M met with Mrs McCarthy’s daughter to provide her with the consent form. She said that the original form was left on the ward, to be collected from the ward when the remains were removed from the mortuary. When the form had not been collected later that afternoon, she became concerned as she knew that this indicated the remains had not left the hospital. She phoned Dr. M who told her that Dr. X was looking after the arrangements. However, in our examination we were unable to find any evidence that these arrangements had been made.
Dr. X said that at 19.00hrs on Tuesday 25November, he received a phone call at home from one of the morticians at Beaumont Hospital telling him that he was concerned about leaving Mrs McCarthy’s remains at St. Mary’s over night, because it was necessary to refrigerate the remains for brain donation. The mortician asked if arrangements could be made for the body to be brought to Beaumont that evening instead. Dr. X said that it had been his understanding, prior to this call, that the mortuary staff in Beaumont Hospital would organise the transportation of the remains from St Mary's, as they are responsible for the removal of remains following a death on a ward at Beaumont. This however, is not the case as outlined by Prof. L., who told the Office that when a post-mortem is requested by another hospital, it is a matter for the referring hospital to arrange the transfer.
Prof. L., having checked with her colleagues, told the Office that none of the pathologists at Beaumont Hospital had been asked either by medical staff at St. Mary’s or by Dr. X or any member of his team, to perform a post-mortem on a patient from St. Mary’s. When investigators pointed to the fact that mortuary staff must have been aware of the planned post-mortem, given that one of them phoned Dr. X regarding the necessity to move the body, Prof. L. could not explain this. She told the Office that there were no records in the mortuary relating to the case, and that it was not possible to trace the consent form which had been signed by Mrs McCarthy’s daughter.
In correspondence with the Office, Prof. L. said that it was
‘important to state that Beaumont Hospital cannot accept any blame for the fact that a post-mortem was not performed on the late Mrs Mary McCarthy. The procedure within the hospital is that if an institution from outside the hospital requests a post-mortem, that they speak directly with a Consultant Pathologist who can decide whether to accept the remains of the patient for an autopsy or not’.
The Ombudsman drew Dr. X’s attention to the fact that no pathologist was aware of the planned post-mortem, and that it had not been accepted in accordance with the procedure provided by Prof. L.. He replied in a letter to the Office dated 11 February 2010, that the arrangements set out in Doc. No. LP-PM-Autopsy did not reflect his experience of how post-mortems had been arranged, whether at Beaumont Hospital or at other hospitals. He stated that it was his understanding that the Pathology Registrar on duty is contacted by a member of the clinical team involved with the patient’s care. He provided the Office with a document which he had downloaded from Beaumont Hospital’s intranet which said that the consent form must be filled in, however it does not mention that the Consultant Pathologist must accept the post-mortem from a member of the clinical team before it can proceed.
In this letter, Dr. X also stated his view that Professor L. and her colleagues in Histopathology were not aware of the planned post-mortem because what was at issue was brain banking and not a general post-mortem. He explained that brain banking was a matter for the Neuropathology Department. He said that he had asked a member of his team to make the arrangements for the brain banking procedure and could not comment on “whether they [the family] had gained an impression that a post-mortem study, as opposed to the banking of brain tissue, was being proposed to them”. In a further submission to the Ombudsman dated 11December 2010, in response to extracts of the draft report, Dr. X stated that he did not recall undertaking to arrange a hospital post-mortem for Mrs McCarthy. He explained that he did not feel there was clinical information to suggest the presence of an unknown cause of death, and stated “there was no reason in my opinion to carry out a hospital post-mortem … the procedure I discussed with Dr. Y was Brain Banking …”. In response to the Ombudsman’s draft report, the HSE stated that at no time did Dr. X agree to arrange a post-mortem.
Investigators also spoke to Professor F., Consultant Neuropathologist at Beaumont, who is responsible for the Dublin Brain Bank, to establish what arrangements had been made for the donation. Prof. F. stated that he was not made aware by either Dr. X, or Dr. Y, that there was a potential brain donation. He also explained that in the normal course of events, where a post-mortem is carried out and some brain tissue is being retained (as opposed to the donation of the entire organ), the Consultant Pathologist for the mortuary, Prof. L., makes the arrangements. (Prof. F. explained that the brain banking procedure takes place at the Neuropathology Department at Beaumont Hospital, whereas if a small amount of brain tissue is to be retained, following a general post-mortem, the post-mortem takes place at the Department of Histopathology. Prof. F. and the Brain Bank are notified following completion of the general post-mortem.) He would not become involved until the post-mortem had been completed, at which point he would be advised that there was brain tissue which could be retained by the brain bank.
Investigators made contact with Dr. Y, Dr. X’s former SHO, who now works in the United States. She stated that she did not see herself as having any involvement in arranging a general autopsy in this case, and that she would not have had any authority to arrange for the transfer of the remains. Her interest was in the brain donation alone. She said that she was not informed that the family had consented to the brain donation, and so assumed that consent had not been given. She said that she would have expected the doctor at St. Mary’s to have contacted her about the consent. To her knowledge this would have been the first donation to the Brain Bank and, for this reason, it would have been significant. Had she been informed that the family had consented, she would then have contacted Prof. F. who would have made the arrangements. However, as she did not know that consent had been given, she had no reason to follow up on the matter.
The Dublin Brain Bank was launched on 22 October 2008, four weeks before Mrs McCarthy died. The Brain Bank allows for the donation of brain tissue to medical science after death, to facilitate research into brain disease such as Alzheimer’s disease and Parkinson’s disease. Donations are usually planned in advance, by the donor, with the knowledge of his or her family, although it is also possible for family members to agree to donation following the death of a loved one. Documents available online show that, in October 2008, highly developed procedures and protocols for donations and consent were in place at the Brain Bank. Beaumont Hospital’s website states that it has a “significant role in informing and supporting those wishing to make a post mortem donation and their families”.
Dr. M stated that Dr. X had asked him to talk to Mrs McCarthy’s family about donating brain tissue to the Brain Bank at Beaumont Hospital. Because Mrs McCarthy’s family was anxious to help research into Alzheimer’s disease, they agreed to the donation. Mrs McCarthy’s daughter annotated the autopsy consent form which Dr. Y had faxed to St. Mary’s Hospital, to show that her mother’s brain could be retained for donation to the Brain Bank. The family was not provided with a separate consent form for the brain donation.
There is no evidence, either in the records of the case, or obtained in interviews during the course of the investigation, to show that the Coroner was told about the falls sustained by Mrs McCarthy on 22 and 23 November, or that he was informed about the head injury and fractured nasal bone revealed by an x-ray taken on the day she died. It is the Ombudsman understands that had the Coroner been advised of the head injury, he would have required that a post-mortem be carried out. On the death notification form, the antecedent cause of death (“Fracture of left pubic rami due to or as a consequence of fall") is shown as having occurred 10 days prior to death, in fact it had occurred in the fall of 17 November, that is, 7 days prior to death.
Having been informed that the Coroner would not be carrying out a post-mortem, the family requested a hospital post-mortem. Dr. M said that, on being advised of this request, Dr. X agreed to arrange for a general post-mortem, as well as brain donation, to be carried out at Beaumont Hospital. This was also the understanding of the family as relayed to them by Dr. M. However, Dr. X states that the only procedure which was to have taken place was brain banking.
At the time of Mrs McCarthy’s death, St. Mary’s had no procedure in place for hospital post-mortems as they did not have the facilities to carry out a post-mortem and they had never had a request for a hospital post-mortem before. Procedures were in place for arranging Coroner’s post-mortems. Despite the HSE’s contention, in its submission to the Ombudsman, that Mrs McCarthy’s remains were to have been moved from St. Mary’s to Beaumont Hospital on 26 November, no evidence has been provided by any of the parties to the investigation to show that arrangements for this transfer had been made. In fact it would appear from the evidence available that no such arrangements had been made.
There was no documentation on post-mortems or brain donation provided to the family by the medical personnel involved to explain the procedures to them. The absence of clear information and briefing by the appropriate people is problematic when it comes to the area of consent in such matters. Apart from the copy of the autopsy consent form, there is no record of any conversation having taken place between Dr. M and Mrs McCarthy’s daughter about what was involved in either a post-mortem or brain donation.
During the course of the Ombudsman’s investigation, Dr. X provided the Office with a draft procedure to be followed should a hospital post-mortem be requested, in future, by the family of a patient of St. Mary’s for whom he has responsibility. The procedure provides that he should be contacted directly in such cases.
The Ombudsman is concerned that a member of the mortuary staff at Beaumont Hospital had enough information about a planned post-mortem to telephone a consultant at home about it, yet no records exist at the mortuary about the case, not even the consent form.
The Ombudsman acknowledges that Dr. X, in his submission, apologised unreservedly to Mrs McCarthy’s family stating that the “that the administrative difficultly in proceeding with the donation of brain tissue to Beaumont Brain Bank should not have occurred”. He said that incorrect information had been given to him regarding the procedures surrounding the brain-banking process.
The picture which emerges regarding events following the family’s request for a post-mortem is one of confusion. There is no doubt that the family requested a post-mortem. However, there is confusion about what was put to Dr. X by Dr. M in the telephone call of 25 November, and disagreement about what Dr. X undertook to arrange. Dr. M understood that Dr. X had agreed to arrange a general post-mortem (an autopsy or a full medical examination post death, as the term post-mortem is generally understood) and subsequently this was the understanding of nursing staff and Mrs McCarthy’s family. However, Dr. X states that his understanding was that brain banking alone was to be arranged, brain banking being a post-mortem procedure.
In his interview, Dr. X stated that it was his understanding that his then SHO, Dr. Y was to handle the practical arrangements. However she told investigators that she did not see herself as having any involvement apart from having sent the autopsy consent form, by fax, to St. Mary’s at 13.09 on 25 November. She said that she would have become involved had she been told that consent had been given for brain banking, as she would have notified Professor F. and Neuropathology. She did not see herself as having any other role in the case.
In any event, a situation appears to have arisen whereby mortuary staff at Beaumont Hospital were expecting to receive Mrs McCarthy’s remains, despite the fact that a post-mortem had not been accepted by a consultant pathologist in accordance with hospital procedure, Neuropathology had not been informed that the family had consented to the brain donation, and no arrangements had been made for the transfer of the remains to Beaumont Hospital.
In the absence of any arrangements having been made by Dr. X, Mrs McCarthy’s remains stayed at the mortuary at St. Mary’s. Had the (erroneous) concern about the question of refrigeration not arisen on the evening of 25 November, it would appear that there would have been a further delay.
It is clear from the evidence that Mrs McCarthy’s family was approached and asked to donate their mother’s brain for research purposes. Dr. Y was clear that this was what was at issue. She stated that if she had been told about the family’s consent it would have been significant as it would have been the first donation to the newly-opened Brain Bank. The annotation on the autopsy consent form signed by Mrs McCarthy’s daughter makes clear that it was her understanding, and that of her siblings, that they had agreed to donate their mother’s brain to medical science. It reads ‘I D**** give my consent to take only my mother’s brain for the brain bank’.
Meetings between investigators and members of the family have established that they were briefed, by telephone, on the process for the removal of the brain, and any effect that might have on their mother’s appearance. They were concerned about this as they wanted to have an open coffin at their mother’s wake. It has not been possible however, to establish who briefed the family. Dr. X stated in his February letter, that what was at issue was brain banking. The HSE, in its submission, dealt with the matter of consent to the retention of brain tissue, stating, with reference to the lack of a separate consent that “this paperwork was not filled in as the family of Mrs McCarthy withdrew their consent to proceed with the brain banking before her body was transferred to Beaumont ..”. From the evidence, the Ombudsman is satisfied that the McCarthy family was asked to consider, and agreed to, the donation of their mother’s brain to the Dublin Brain Bank for medical science.
The evidence shows that there was confusion among the medical staff involved about what procedures were to have been carried out after Mrs McCarthy’s death, that is, whether brain banking alone, or a post-mortem plus brain banking was to have been done. There was also a complete lack of understanding about how the practical arrangements should have been made, and who was responsible for them. This, combined with the fact that Beaumont Hospital was not informed, by Dr. M / Dr X’s team, that the family had consented to the brain donation, meant that no procedure took place. The brain donation, which would have been the first to the newly opened Brain Bank, did not happen.
Communication failures are dealt with in Chapter 5.
In response to the draft report, the HSE stated that at no time did Dr. X agree to arrange a post-mortem.
The HSE accepted that the Coroner had not been notified of all the relevant information in this case.
The HSE stated that there are now specific procedures in place for dealing with requests for post-mortems at St. Mary’s, whether recommended by clinicians, or at the request of families. At the time of writing, a copy of the procedure is awaited. The Ombudsman has also been informed that training in procedures for post mortems will be included in induction training for NCHDs.
The HSE acknowledged the confusion which surrounded the donation to the Brain Bank, and stated that it deeply regretted the distress that this caused Mrs McCarthy’s family.
The Ombudsman finds that Dr. M, SHO, did not notify the Coroner of all relevant information in this case and that, under the Ombudsman Act 1980, this was based on an undesirable administrative practice (4(2)(a)(vi)), and contrary to fair or sound administration (4(2)(a)(vii)).
In its response to the Ombudsman’s draft investigation report, the HSE accepted this finding.
Given its governance structure, and its relationships with the Mater and Beaumont hospitals, the Ombudsman finds that the absence of a procedure for handling a request for a hospital post-mortem caused confusion in this case, that the medical personnel of St. Mary’s are responsible for this matter, and that, under the Ombudsman Act 1980, the lack of a procedure or protocol (even if this is that post-mortems are not done) was based on an undesirable administrative practice (4(2)(a)(vi)).
In response to the Ombudsman’s draft report, the HSE told the Office that a procedure is now in place and the Ombudsman welcomes this.
It is clear from the preceding sections of this report that there was confusion within the medical team about what post-mortem procedure was intended, that is, whether a general autopsy (commonly known as a post mortem) was to have taken place, or whether brain banking alone was planned. In any event, Dr. X undertook to arrange a post-mortem procedure and, as Mrs McCarthy’s consultant, was ultimately responsible for it. The Ombudsman also acknowledges that Dr. X has apologised unreservedly to the family on a number of occasions, including in person when he attended a meeting with them in St Mary’s Hospital. Nonetheless, I find that, having agreed to arrange a post-mortem procedure, Dr. X did not make adequate arrangements to ensure that it would take place at Beaumont Hospital. This was the result of an undesirable administrative practice (4(2)(a)(vi)), and contrary to fair or sound administration (4(2)(a)(vii)) under the Ombudsman Act 1980.
The Brain Bank had highly developed protocols and procedures in place for donations at the time of Mrs McCarthy’s death. Arrangements should have been made for her family to have been fully briefed by a medical person from the Brain Bank to ensure informed consent, and a separate consent form should have been provided to them for the purposes of the donation. The fact that such arrangements were not made by Dr. X and his team constitutes undesirable administrative practice under section 4(2)(a)(vi) of the Ombudsman Act 1980, and was contrary to fair or sound administration (4(2)(a)(vii)). Had the Brain Bank been asked to become involved formally, at an early stage, the donation might have proceeded.
Mrs McCarthy’s family complained about general aspects of their mother’s personal care while she was resident at St. Mary’s. They told investigators that she was given incontinence wear despite the fact that she was assessed as being fully continent. Their view was that this was for the convenience of staff. They also said that her personal hygiene was neglected on occasion, and that, at times, it could be over a week between times when she was showered. The family said that at times Mrs McCarthy’s appearance was untidy and dishevelled. They said that they were not allowed to help their mother to shower, although they were allowed to give her a bed bath. They also complained that there was no social activity or Occupational Therapy organised for their mother and that there was nothing for her to do. They complained about the physical environment of the ward.
The statement of complaint to the HSE said:
It is contended that there was a poor standard of care for Mrs McCarthy in St. Mary's Hospital; this included a lack of social/recreational activity for her as a resident of Rhiannon ward at St. Mary's Hospital. It is also contended that standards of care related to personal hygiene were poor.
In its submission, the HSE said that the importance of personal hygiene is understood by all staff at St. Marys in the care of older adults and that “staff endeavour at all times to achieve excellence in this area”. However they said
It was often difficult for staff to meet Mrs McCarthy’s hygiene needs to the level that is the normal standard for St. Mary’s Hospital. Mrs McCarthy had severe dementia and demonstrated very challenging behaviour frequently. On some days she was more agreeable than others as regards washing, dressing, showering and general grooming. On other days when staff tried to attend to her hygiene needs, she did not cooperate and on numerous occasions physically struck and pushed staff away.
The HSE said that on occasion, when she was particularly agitated, “it was not possible to meet her hygiene needs”. They said that insistence on “hygiene interventions” would have caused her distress and would have been “counter- productive to her well being and health”. The submission went on to say that Mrs McCarthy’s family were often present at the hospital and did bring this issue to the attention of staff. Staff explained the difficulties and the family, the submission states, appeared to understand.
Dr. X, in his submission said that he did not accept that Mrs McCarthy’s personal hygiene was deficient. He said “inadequate personal care commonly results in problems such as skin breakdown or rashes such as interigo, oral mucosal injury and infestations with commonly occurring pathogens (e.g. scabies)”. He said that Mrs McCarthy’s clinical condition did not show any evidence of these problems.
The matter of continence management was not specifically mentioned in the statement of complaint as it was a matter which arose during interviews with the family in the course of the investigation. It was raised with the Director of Nursing and other staff of St. Mary’s Hospital in the course of the investigation.
The matter of social/recreational activity was specifically mentioned in the statement of complaint; however the HSE did not address it in its submission.
The matters of the physical environment of Rhiannon Ward, and Mrs McCarthy’s safety, were not specifically mentioned in the statement of complaint as these were matters which arose during interviews with the family. These matters were raised with the Director of Nursing and other staff of St. Mary’s Hospital in the course of the investigation.
Mrs McCarthy’s daughters said that, while she was at St. Mary’s, their mother’s personal hygiene was not always good. They said that their mother was not showered frequently enough and that her appearance was untidy at times. Her daughter described one incident where she had gone to the hospital early to help wash and dress her mother. When she was dressed, a healthcare assistant came into the room and said that Mrs McCarthy was to have had a shower that day. She offered to get her mother undressed for the shower but the healthcare assistant said she could have the shower the next day instead. Three days later Mrs McCarthy had still not had her shower. Her daughter complained, saying that it was not acceptable, and her mother was given a shower after lunch that day. The family did not accept that their mother’s behaviour was such that she would refuse to be showered.
In her interview with investigators, the then Director of Nursing, stated that there was one shower for the twenty-eight patients on Rhiannon Ward. She said that people were guaranteed a shower once a week and that each person was washed every day. In her submission dated January 2011, in response to extracts of the Ombudsman’s draft investigation report, the former Director of Nursing contended that there was “vagueness in the complaint”. She also stated that lack of showering facilities was not the reason that residents were not showered every day, and that many older people, particularly those with dementia, are not anxious for showers every day. She said that the weekly shower was a minimum, that many residents have more frequent showers if they want them but that, equally, staff won’t force residents to shower “just to achieve organisational standards”.
When asked by investigators whether Mrs McCarthy’s family had raised concerns about their mother’s personal hygiene, Nurse C said that they had. She explained that the facilities on the ward are limited and that staff try to ensure that patients are showered once a week. She also pointed out that nursing staff had to work within the realm of consent and that staff wouldn’t want to overrule the wishes of patients and insist on washing them if they did not want to be washed. She explained that Mrs McCarthy could be very agitated and unsettled in the morning but more settled in the afternoon after her medication. For that reason staff sometimes washed her in the afternoon. She said “it wasn’t that her hygiene needs weren’t being met, it was just that we had to manage it in a different way in accordance with her mood”.
Nurse H stated in her interview that patients were showered once a week, in so far as possible. She explained that if Mrs McCarthy’s behaviour was very challenging no shower would be given that day, and that each patient had a bed bath every day. Nurse H could not recall the family complaining about Mrs McCarthy’s personal hygiene. Nurse F also said that patients were showered once a week, explaining that as there is only one shower it is very difficult. She said that she would love to be able to shower her patients every day if they wanted a shower, but said “it is physically not possible because the resources are not available”.
The Ombudsman has examined Mrs McCarthy’s daily care record from the date of her admission to the date of her death. The records show the care given from Monday to Sunday for each of the seventy-eight weeks. The records show that for forty-nine out of the seventy-eight weeks, Mrs McCarthy was showered at least once and that out of these forty-nine weeks, there were five occasions on which she was showered twice in the same week. For twenty-nine of the weekly periods, the record shows that she did not have a shower and instead either had an assisted wash or a bed bath. The longest period between showers, according to the record, was thirty days. There were five occasions where the intervals between showers were between twenty and twenty-six days, four occasions where it was fifteen to nineteen days, and ten when the interval was between seven and fourteen days. The record showed twenty-two intervals of six days or less.
An analysis of the daily care plan documentation provided shows an entry under the ‘Bathing’ heading for most days apart from days on which Mrs McCarthy had a shower. Most of these entries are bed baths. The longest gap between bed baths is two days.
The daily care record shows a high level of daily care for Mrs McCarthy, albeit in the form of bed baths (which St. Mary’s has described as full body washes) instead of showers. However, the family described problems with Mrs McCarthy’s personal hygiene, and the hospital admitted, in its initial submission, that there were problems in keeping her level of hygiene to the usual standard. These two things are not consistent with each other. If Mrs McCarthy was having a full body wash every day, it is unlikely that there would have been problems with her personal hygiene. During the investigation, investigators wrote to St. Mary’s seeking an explanation as they wondered whether the level of bed baths was not as high, in practice, as shown in the daily care record.
In its further submission dated 7 October 2010, the hospital again stated that “staff did have difficulty keeping Mrs McCarthy’s personal hygiene at the standard that was normal for St. Mary’s hospital”. It stated that Mrs McCarthy was provided with full body washes at her bedside, which is an acceptable alternative to showering for people with dementia. The submission says that these washes were described as bed baths in the notes. It again made the point that Mrs McCarthy found showering distressing. The submission states that staff found it difficult to assist Mrs McCarthy with washing her hair, using bed bathing techniques, as this required co-operation from the patient which “was not possible given Mrs McCarthy’s cognitive status and physical limitations”. The submission says that this affected her overall appearance and her family’s perception of her level of hygiene. It states “She was never left unclean or unkempt by staff and they tried their best to maintain a high level of hygiene for Mrs McCarthy without forcing or upsetting her and respected the fact that she was upset when showering was attempted”.
The submission goes on to comment as follows on the standard of record keeping in the daily care record “In relation to the record keeping, I recognise it as an unacceptable standard of documentation. The system of documentation has been reviewed and revised and is monitored through continuous audit which has shown a marked improvement”.
Mrs McCarthy’s family said that their mother wore incontinence wear (pull-up disposable pants) despite the fact that she was fully continent. Their view was that this was for the convenience of the staff. They said that when they queried the use of this sanitary wear, they were told that their mother was having some accidents. They said that their experience was that their mother did not have accidents when they took her out for the day, and that she was able to tell them when she wanted to use the toilet.
Nurse C said that Mrs McCarthy was continent but had episodes of incontinence. She said that pull-up pants are recommended for people who are incontinent but also for people who are mobile and can toilet themselves so that they can pull them up and down. Other types of sanitary wear (a slip pad) had been tried instead, but Mrs McCarthy could not manage these herself. Nurse C said that in the latter stages of her illness, Mrs McCarthy couldn’t verbalise that she wanted to use the toilet. Staff relied on non-verbal signals. Pull-up pants were considered to be the most appropriate for her because she did soil her clothes on occasion, particularly towards the latter stages of her illness.
Nurse H said that Mrs McCarthy was not incontinent but was wearing pull up pants for her protection. She said it was not policy to put incontinence wear on patients, but that she wore them at times in case of accidents. She said that the family had never raised this as a problem. She explained that dementia patients are assessed and their personal toileting pattern is established so that staff can assist them at the appropriate times. She said that Mrs McCarthy was not able to tell staff when she needed to go to the toilet.
The Director of Nursing said that it was not hospital policy or practice to put continent patients in incontinence wear. She said that over many years the hospital invested in education on and management of incontinence and the care plans reflected that.
The records show that on admission Mrs McCarthy was assessed as continent, as toileting independently, but as wearing incontinence pads in case of accidents. Further records show that she was assessed, on a number of occasions, and as late as July 2008, as being doubly continent. Later in her illness she needed assistance with toileting. The records also show that, from the date of her admission, she was assessed as requiring Tena Pull-up pants in the day and another sanitary product at night. This was at a time when she was assessed as being fully continent.
With her submission of January 2011, in response to extracts of the draft report, the former Director of Nursing provided a Barthel Index (an assessment of activities of daily living) for Mrs McCarthy which showed that Mrs McCarthy was assessed, on 15 August 2007, as having occasional accidents (once a week or less) of bowel, and occasional accident (daily or less) of bladder. This assessment had not been provided to the Office previously, despite a request for all records related to her care. Also in that submission the Office was told about an “Essence of Care Project” in place at the time of Mrs McCarthy’s stay which addressed continence management. The former Director of Nursing said that the type of protective pants worn by Mrs McCarthy was sanctioned as part of the project, despite their expense, as it was judged that they gave some residents more independence and dignity. While St Mary’s did not have a continence policy in place at the time of Mrs McCarthy’s stay, the former Director of Nursing has advised the Office that a policy is now in place. She drew the Ombudsman’s attention to the section of the policy dealing with pull-up pants which states that they are “useful for older patients with light incontinence who cannot manage other pads but can toilet independently using ‘Pull-Ups’”.
Mrs McCarthy’s daughters visited her frequently. They explained how they brought her out to the greenhouse at St. Mary’s, how they would bring up knitting for her to do, and how, when she was first admitted, she would play cards with them. They also took her out for the day on a regular basis. They felt that, apart from their interaction with her, there was nothing for her to do at St. Mary’s. They were critical of the failure to provide their mother with suitable therapeutic activities. They said that she liked gardening and that they treasure a painting which she did on the only occasion she attended a painting class at St. Mary’s. They described looking at photographs of other residents on day trips and regretted that their mother was never included in these outings.
Investigators put it to the Hospital that Mrs McCarthy had nothing to do on the ward and that no activities were organised for her. In response, Nurse C said that Mrs McCarthy was not able to participate in group activities due to her dementia. When asked about the activities provided at St. Mary’s, she explained that these are organised by activities staff at the hospital, in conjunction with nursing staff on the ward. In the morning there is Mass, followed by either bingo, the film club, yoga, music, or dancing. These activities take place in the ‘mass room’ just beside Rhiannon Ward. Nurse C said that in the afternoon a staff member attends to those patients who do not attend the morning activities and focuses on patients who cannot interact with others. The important role played by Mrs McCarthy’s family in her social interaction and activity on a day to day basis was acknowledged, as were the positive effects on her of these interactions with her daughters.
With regard to therapeutic activities organised by the Hospital, Nurse C explained that when Mrs McCarthy was first admitted she was better able to participate in group activities, but that she was also prone to aggressive and violent behaviour at times and sometimes lashed out at other participants. When this happened, the other participants would leave because they were afraid. Nurse C said that Mrs McCarthy used to go to mass but, in the later stages of her illness, she would get up mid-way through. She had a poor attention span which didn’t allow her to sit and this, combined with highly compromised ability to verbalise or communicate, made participation in group activity difficult. For this reason, staff tried to engage her in daily activities as they went around the ward. They would bring her with them as they made the beds and, if appropriate, took her with them if they were going around the hospital. Mrs McCarthy also liked to go out for a cigarette. Staff would accompany her when she wanted to smoke and would try to engage her in one-to-one chat. Nurse C felt that she did not have the capacity to participate in group activity and that this one-to-one contact was better for her.
In her interview, Nurse H said that once each year the residents are taken to Knock, Co. Mayo. There were two or three women who would be taken on outings in between, but Mrs McCarthy was not considered able for these outings. She was taken out to the garden to smoke a cigarette, but she was not taken outside the hospital by staff.
No records were provided to the Ombudsman, at the initial stage of the investigation, of Mrs McCarthy having been assessed by an Occupational Therapist at St. Mary’s. Investigators found no references to Occupational Therapy in either the medical or nursing notes (apart from a referral for a seating assessment on 23 November 2008).
St. Mary’s did provide the Office with some records related to Mrs McCarthy’s organised activities while she was resident there. A form dated 6 August 2007 entitled “Activities” was filled out for Mrs McCarthy. It is attached at Appendix 3. It shows that her mobility status as independent. The space for past hobbies and interests is blank, as is the section for ‘Previous Occupation’ and ‘Further Information’. The nursing intervention states that Mrs McCarthy would attend mass, assisted by staff, “when possible on weekdays and Sundays”. It also states that she will attend Sonas, and an exercise programme as organised by Recreational Therapeutic Activity Staff on the Unit. (Sonas is a group activity, developed for people with dementia, which focuses on stimulating the five senses.) For the period of her stay at St. Mary’s (nineteen months), organised social and therapeutic activities are recorded for nineteen days (twenty-four activities over nineteen days). She did attend a painting class on 28 June 2007, shortly after her admission, and the notes state “Mary seemed to really enjoy completing a painting this pm”. There is no entry to show that she attended the painting class again.
|Month||No. of organised activities||Activity|
|October 2007||6||Sonas, Bingo, Exercise, Snoezelen (Snoezelen is a session of controlled multisensory stimulation. It is used for people with cognitive impairment, and involves exposing them to a soothing and stimulating environment.)|
|November 2007||4||Massx2; Bingo; Walk outdoors|
|January 2008||3||Exercise x2; Sonas|
|June 2008||1||Exercise Group|
|July 2008||3 (all on 1/7/08)||Coffee and Prayers; Walk outdoors; Exercise Group|
|August 2008||1||Coffee and prayers|
|October 2008||1||Hand and nail care|
The records show that Mrs McCarthy was sometimes brought to group activities on other occasions which are not documented on the activities sheet. For example, a note in the nursing notes for 9 August 2008 states “brought her to activity group but she couldn’t stay in the group as she is restless’’, and on 17 August 2008 the nursing notes state “unable to relax and concentrate to activity group”.
Because of the lack of Occupational Therapy documentation, and the low level of documented organised therapeutic activity for Mrs McCarthy, investigators wrote to the hospital again on 23 September 2010. The evidence, as set out above, was provided to the Hospital. Investigators put it to the Hospital that the level of organised activities recorded for Mrs McCarthy appeared to be extremely low. They also pointed out that there did not seem to have been any assessment by an Occupational Therapist, or by any health professional, of her capacity to participate in activities of various sorts, and no plan for such activities. Observations on this were invited prior to the finalisation of the draft investigation report.
In its reply, the Hospital stated that the form entitled “Activities”, referred to above, provided at Appendix 3, was the assessment, on admission, by the Activities Nurse, of Mrs McCarthy’s ability to participate in activities. The hospital said that staff did encourage Mrs McCarthy to take part in the recommended activities, that is, mass, Sonas and exercise. It did not contest the level of activity as shown by the records, but said “it is quite common for patients with dementia to lose interest in groups or organised activities ... staff frequently took Mrs McCarthy for walks, put on music, encouraged her to sing and dance with them. This is often of most benefit to the patient”.
Regarding Occupational Therapy for Mrs McCarthy, the hospital provided the Office with a letter from the Occupational Therapy Manager. The letter stated that an Occupational Therapy file for Mrs McCarthy could not be found. The OT Manager said that she was the Occupational Therapist assigned to Rhiannon Ward when Mrs McCarthy was resident there. She said that she did remember some of her involvement with her, but that she did not have any documented evidence of it.
She stated that her system showed that Mrs McCarthy was referred to the Occupational Therapy service on 21 April 2008, “with a request to establish her leisure needs”, and again on 1 October 2008, “to review her mobility and cognition”. Neither referral appears in either the nursing or medical notes; nor does the outcome of any referral. The Occupational Therapy Manager stated that she recalled involving Mrs McCarthy in a “Luncheon Club” and a “Music Group” while she worked there. She explained that the Luncheon Club was where she attended meal time daily “in an effort to support an improved dining experience” for residents. She said that Mrs McCarthy was included in this activity where residents were encouraged to sit in groups of four and supported to “interact and engage in a meaningful manner”. She said that Mrs McCarthy was a regular attendee at the music group.
Mrs McCarthy’s family complained about the physical environment of Rhiannon Ward. As described above, the ward was comprised of several rooms off a central corridor which made supervision of patients difficult for staff. The ward had one shower room for 28 patients. The family had concerns about patient safety and complained that their mother had wandered out of the ward unaccompanied and was found in the grounds of the Hospital. Incident reports on the hospital’s files show that Mrs McCarthy left the ward unaccompanied on two occasions, at 10.00hrs on 27 April 2008, and on 21 May 2008 at 22.00hrs. On both occasions she was found in the grounds and returned to the ward by nursing staff.
Mrs McCarthy slept in an eight-bedded room (called Ward 2) on Rhiannon. Her bed was closest to the room door, and, accordingly, was relatively near the ward exit. The door of Rhiannon Ward leads to a small lobby and then to an external door. The grounds of St. Mary’s Hospital are relatively near a main road. With regard to patient safety, the Director of Nursing explained that St. Mary’s had a tag system, the WanderguardTM system, for patients on Rhiannon Ward who were at risk of wandering. She said that Mrs McCarthy wore such a tag on her ankle. If she went near the ward door, a buzzer sounded and a mechanism locked the door. Mrs McCarthy’s family confirmed that she wore the tag at all times. The Director of Nursing explained that the only way a patient wearing a tag would go out, was if someone opened the door for them. She said this did sometimes happen. She explained that on the occasions Mrs McCarthy went outside and was found in the grounds, staff had looked out when the buzzer sounded, but saw no one on the corridor near the door. Mrs McCarthy was already outside. On each of the two occasions Mrs McCarthy was located quickly and returned to the ward with staff.
The Ombudsman was told that the external door to Rhiannon Ward remained unlocked until approximately 9pm. It was, therefore, possible for anyone to walk onto the ward from outside. There was no system in place, such as a door entry buzzer system, which required staff to admit visitors, even in circumstances where the door to the ward was separated from the external door by only a small lobby.
In response to extracts from the draft report, the former Director of Nursing said that the main entrance to the hospital is staffed by a porter on a twenty-four hour basis, who also “has clear vision of the other entrance”. She said that the door to Rhiannon ward has a CCTV camera which “is not manned constantly, but supports the security system”. She rejected the view that the grounds are not enclosed. In relation to their being no admitting system, she said that St. Mary’s is not a locked facility and that Rhiannon Ward is “within the safety of the campus of St. Mary’s”.
The family complained that the common areas on the ward were inadequate for the number of patients, and that there was no room in which to have a private consultation or visit. Rhiannon Ward has one day room which also serves as a dining room. The only other common area was the corridor of the ward which was also used as a seating area. On occasion, Mrs McCarthy’s daughters took her to the greenhouse in another part of the hospital for their visits. There was no room in which they could have had a private visit.
The Ombudsman was told that there is one single room on Rhiannon Ward available to a very ill or dying person. The room was already occupied by an extremely ill woman at the time of Mrs McCarthy’s death. Mrs McCarthy died in an eight-bedded room on the ward, with limited privacy provided to her and her family by a curtain around her bed. After their mother’s death, the family said that nursing staff had asked residents to leave the day room/dining room, in order to give the family a private space. While the family appreciated this gesture by the nursing staff, they found it unacceptable that residents were asked to leave the room.
It has been accepted by the Hospital that at times it was not possible to keep Mrs McCarthy’s personal hygiene to the usual standard for St. Mary’s. The reason given for this is that her mood and behaviour meant that washing her was problematic. However, an analysis of the daily care plan documentation provided by the hospital shows an entry under the ‘Bathing’ heading for most days, apart from days on which she was given a shower. Most of these entries are bed baths, and the hospital has explained that this meant that Mrs McCarthy had a full body wash at the side of her bed. The record shows that the longest gap between bed baths is two days. The level of bed bathing described is not consistent with failures in hygiene standards observed by the family on some occasions. If Mrs McCarthy had had a full body wash at the level of frequency described in the records, it is unlikely that problems with personal hygiene would have arisen.
When the Ombudsman provided the family with the evidence, from the records, regarding the frequency of showers their mother received, they were surprised and did not think that it reflected the practice – that is, they thought that she was showered more frequently than the record showed. They also agreed that she was washed frequently, but did not think, from their observations, that she had a full body wash at the frequency described in the records. The family remained of the view that their mother should have been showered more frequently, and said that it was not their experience that she did not like to be showered. Her daughter said that when she brought her home for the day at weekends, she would allow a hairdresser to wash and style her hair. She did say that the hospital staff may have done their best within limited resources, but said that, in her view, resources were inadequate and the standard was not as good as it should have been.
In her submission of January 2011, which followed her receipt of relevant extracts of the draft investigation report, the former Director of Nursing provided new information on this matter. She presented evidence which showed that Mrs McCarthy was assessed as having accidents. She also provided information on a policy which was in place which the Office had not been made aware of previously. On the basis of this new information, it would appear that Mrs McCarthy’s continence management was within the policy in place.
The Social and Recreational Therapeutic Activities recorded for Mrs McCarthy for the time she was resident at St. Mary’s are extremely low in number. There were no assessments, despite changes in Mrs McCarthy’s condition and capacity over time, by an Occupational Therapist or another suitably qualified person, of her capacity to participate in activities of various sorts, and no plan for such activities. The Hospital said that the form dated 6 August 2007, entitled “Activites” (attached at Appendix 3) is an assessment, on admission, of Mrs McCarthy’s ability to participate in activities. The Ombudsman does not consider that this document contains sufficient information about Mrs McCarthy’s past interests, experience and hobbies to inform an activities care plan for her. A nursing evaluation chart lists incidences where Mrs McCarthy participated in activities, and assesses this involvement, but there is no evidence that there was any follow-up or periodic assessment of the value of these interventions.
There is no evidence that there was an individualised plan of activities for Mrs McCarthy as her dementia progressed. Dementia-specific therapeutic activities such as Sonas were provided at the hospital, but the record shows that her participation in these was infrequent. It would seem that formal, structured, one-to-one therapeutic activities for Mrs McCarthy were not considered.
The Clinical Nurse Manager described one to one attention given while carrying out routine tasks. Staff would take Mrs McCarthy with them for walks when they were going to collect drugs, or take her with them when making the beds in the ward and allow her to help. This is valuable social interaction and investigators were impressed that some staff members at St. Mary’s seemed to know Mrs McCarthy’s likes and dislikes very well, and to genuinely care about her, however, there is nothing on the record to show that, following an assessment of her capabilities at particular times, certain activities were considered appropriate to her needs.
The physical environment of Rhiannon Ward is clearly problematic in several respects. Chapter 2 on Falls Management, provides evidence of problems posed by the ward layout for supervision of patients, such as Mrs McCarthy, who were vulnerable to falls. This chapter demonstrates that the layout also posed problems for supervision of patients who had a tendency to wander, as Mrs McCarthy did. The part of this Chapter dealing with personal hygiene, demonstrates the poor provision, in terms of physical infrastructure, of showering facilities for the number of patients on the ward, and the limitations this imposed on their opportunities to shower. Mrs McCarthy was directly affected by all of these deficits in the physical environment.
Safety must be of paramount importance for dementia patients and it would appear, from the evidence, that Mrs McCarthy’s location on the ward exposed her to unnecessary danger, given her tendency to wander and the proximity of her bed to the external door which was open until 9pm. A security system which relies on patients being visible to staff to track their whereabouts does not seem appropriate given the layout of Rhiannon Ward. This is evidenced by the fact that Mrs McCarthy left the ward on two occasions, once at 10 o’clock at night.
Based on complaints to the Office of the Ombudsman on the subject, the Ombudsman has commented previously on the importance of improved facilities for those who are dying and for their grieving loved ones (“End of Life Care: From the Margins to the Mainstream” address by Ms. Emily O'Reilly, Ombudsman, at the Hospice Friendly Hospitals National Conference on End of Life Care, 19th May 2010). In the course of this investigation the Ombudsman asked the HSE whether there was a private room into which Mrs McCarthy could have been moved when she was very ill and dying. The HSE said that Rhiannon Unit has a single room which is always offered to ill or dying residents and their family members. However, it was not offered to Mrs McCarthy as her condition deteriorated very rapidly and her death was unexpected. The HSE stated in its response “Every effort is made in respect of patients who are dying to provide them with dignity and the privacy of a single room”.
In relation to having access to a room in which the family could have private visits, the HSE stated that had the family contacted Nursing Administration, this could have been arranged. The Ombudsman does not find it acceptable that a family should have to go to such lengths to have time alone with their mother when visiting her in the nursing home which, as the HSE also pointed out it its response, was her home.
In its response to the draft investigation report, the HSE stated that residents on Rhiannon Ward were not limited to showering once a week, stating
“... this is the frequency with which elderly patients usually agree as experienced by nursing staff. If there is a hygiene infection or other clinical need, showers are insisted on at more frequent intervals”.
It went on to say
“The purpose of hygiene is to protect skin integrity and prevent against bedsores, skin breakdown rashes etc. There is no evidence that Mrs McCarthy suffered from any of these ...”.
The HSE pointed out that Rhiannon Ward is a residential care setting in St. Mary’s and is not a hospital “St. Mary’s is a nursing home and residents live there as an alternative to their own home”. The HSE also stated that it is committed to improvements in St. Mary’s “on an incremental basis”. It said that two new buildings had been provided with the capacity for 150 residents, and that all of these rooms have an en suite shower “to be used as per patient requests and requirements”. It stated that despite the availability of these facilities, the majority of these residents will only agree to a weekly shower.
In response to the Ombudsman’s Draft Investigation report, the HSE stated, in relation to the physical environment of Rhiannon Ward:
“... there are ongoing incremental developments and improvements at St. Mary’s. It is acknowledged however that there are some environmental factors which may restrict systems with regard to health and safety. However all risks are reviewed on a continuous basis and quality improvements instigated to mitigate risks.”
The HSE has told the Ombudsman that a recreation room (Mass Room) adjacent to Rhiannon Ward was available for family visits every afternoon and at weekends, and that this room is used by people who want private time with their families. In addition, as one of a small number of smokers, the Ombudsman is told that Mrs McCarthy and her family generally had the smoking lobby to themselves.
It is undisputed that the severity of Mrs McCarthy’s condition posed challenges for staff at St. Mary’s, nonetheless, St. Mary’s sees itself as providing specialist care for the elderly, many of whom have dementia, and all areas of the hospital should deliver quality care to its patients. The Ombudsman finds the following:
The Ombudsman finds that there was no maladministration in this matter.
The family complained about communication between themselves and the hospital in the week of their mother’s death, and, in particular on the day of her death. They said communication with them about falls sustained on 22 and 23 November was abrupt and inappropriate. They also complained that the doctor who attended their mother one hour before her death did not engage with them and did not tell them that their mother was dying. As a result, they did not call other siblings to their mother’s deathbed. Furthermore, they complained that when this doctor returned following their mother’s death, to examine and pronounce her dead, she did not offer her condolences to them. They also complained that an insensitive phone call to them following their mother’s death, regarding the transport of her remains for post-mortem, caused them huge distress and led to the cancellation of the post-mortem, which they had requested, and the donation of their mother’s brain tissue for research purposes. The family now regrets that neither the post-mortem, nor the brain tissue donation happened. Finally, they complained about the failure by the hospital to inform them about a fractured nasal bone.
Accordingly, the complaint which related to communication had four parts:
The relevant extract from the statement of complaint is as follows:
"It is contended that communication between medical staff at the hospital and Mrs McCarthy's family was very poor, particularly on the day of her death, and that this caused distress to them and resulted in members of the family not having been called to their mother's deathbed as the seriousness of her condition was not explained. In addition, it is contended that poor and inappropriate communication by the hospital with the family, related to their donation of brain tissue to Beaumont Hospital, caused them serious distress and ultimately resulted in the withdrawal of their consent for a post-mortem which they had originally requested."
The matter of the fractured nasal bone was raised later with the Hospital and was addressed in the HSE’s submission to the Ombudsman’s Office.
On the matter of communication regarding the un-witnessed falls of 22 and 23 November 2008, the submission from the then Director of Nursing stated that the Clinical Nurse Manager had spoken to the nurse on duty that night, regarding her style of communication with the family. The submission states “the nurse stated that she felt that the family were making accusations and she became defensive... she understands how her communication style affected the McCarthy family and stated she did not intend to cause any upset. She apologised for any upset caused.” This apology was passed on to the family in a letter by the then Director of Nursing dated 19 January 2009.
Dr. X responded to the Office on the matter of communication by Dr. A, SHO, prior to Mrs McCarthy’s death. He said that he did not consult with her prior to making his submission. He said that he did not communicate personally with the family but apologised “if unclear communication from Non-Consultant Hospital Doctors (NCHDs) contributed to distress among Mrs McCarthy’s family”. He stated that in many cases it can be unclear that a patient is about to die, and that many NCHDs “may not have experienced a patient who is about to die in their brief clinical experience on their own”. He explained that in acute hospital settings, NCHDs are supervised more closely by senior clinicians who often decide whether to alert the family about the possibility of death. He felt that these factors may have contributed to the family “feeling distressed about inadequate communication’’, and stated his view that effective communication develops with increased clinical experience.
Regarding the phone call about the transportation of Mrs McCarthy’s remains for post-mortem at Beaumont Hospital, the HSE in its submission, stated that the transfer of remains for a post-mortem was “an unusual and unprecedented occurrence”. It stated “St. Mary’s intervention was purely to assist and attempt to regularise the situation”. In her submission, the Director of Nursing explained that Mrs McCarthy’s body was to have been transferred on 25 November “but that did not happen”. She said that Dr. X was advised that it was necessary for the body to be moved for overnight refrigeration, and so phoned the Assistant Director of Nursing (now retired) at 7pm to see if this could be arranged. She in turn phoned Mrs McCarthy’s daughter to arrange the transfer. The submission stated that she was upset that her mother’s remains were still at St. Mary’s (she had died the previous day at 5.30pm). The HSE submission to the Ombudsman said that the hospital contended that the communication was “handled as sensitively as possible given the circumstances”.
Mrs McCarthy’s family was not aware that the facial x-ray taken on 24 November 2008 (the day their mother died) had shown that she had a fractured nasal bone. This is despite the fact that they had met with the Consultant Geriatrician, the Director of Nursing, the Assistant Director of Nursing, and the Clinical Nurse Manager in January 2009 about, among other things, the falls their mother sustained in the weeks prior to her death. The family became aware of this fact in a meeting with this Office’s investigators in June 2009. In it submission, the HSE stated that it was advised by the former Director of Nursing that she was unaware that the family had not been told about the fall and fracture. The Ombudsman was told by the HSE that “it is the policy of the HSE at all times to advise families of any adverse incidents which may occur, which effects the relatives directly while a patient is in the care of the HSE”.
In her interview, Nurse F, who was on night duty on 22nd /23rd November when two falls occurred, apologised if her communication style caused offence to the family. She spoke to the family by telephone in accordance with the Hospital’s protocol to advise families of such events straight away. She said that she did not recall exactly what she had said, and acknowledged that it would have been very upsetting for the family to be told that their mother had fallen. She said that it is very upsetting for everyone when a patient falls, especially for the patient, but also for family and for staff. She asked this Office’s investigators to apologise to Mrs McCarthy’s family again if she had caused offence by the way she had told them about the falls, and acknowledged that her style of communication can be direct sometimes. She said that she did not intend to upset them. She also asked this Office’s investigators to sympathise with the family, on her behalf, for their loss as she had not seen them since Mrs McCarthy died.
Investigators interviewed Dr. A., the doctor on call who had attended Mrs McCarthy approximately one hour before she died, and who subsequently came to the ward to pronounce her dead that evening. She did not know Mrs McCarthy and had not met her or her family before that day. Investigators put it to her that Mrs McCarthy’s daughters felt she did not engage with them at all when she attended their mother, and that she did not tell them that she was dying. Their impression at that time was that Dr. A. did not know that their mother was dying. However, when they asked the nurses they were told that yes, she was dying. They found these conflicting messages confusing and distressing.
When interviewed, Dr. A. could not recall actually having a conversation with Mrs McCarthy’s daughters, although she did recall them having been around the bed when she came to examine their mother. Nurse E., in her interview, recalled that the Doctor did talk to the family, but did not recall what had been said. Having re-read her own contemporaneous notes, Dr. A. said that she had prescribed morphine to make Mrs McCarthy comfortable, and this indicates that she did anticipate that death was imminent. She stated that it would not have been possible to predict exactly when the patient was going to die and that she had seen patients in the same condition for 24-48 hours. When asked if she would normally communicate with families about death, she said that she would have explained that she was adding medication to make the patient more comfortable. She said that, based on her medical plan, and the fact that the daughters were there at the time, she imagined she would have talked them through the plan. There is no record in the medical notes of Dr. A. having explained Mrs McCarthy’s condition to her daughters.
Dr. A. said that she did not have experience of dealing with families of dying patients prior to her work at St. Mary’s, which was her first post as a Medical SHO. She said that she had been satisfied that her medical plan for Mrs McCarthy was appropriate and would have relayed it to the family to the best of her ability based on her experience at the time. She explained that SHOs are the only doctors on duty in St. Mary’s in the afternoons and that, ideally, from a learning point of view, there would be a more experienced doctor available at the hospital when patients were very ill or dying.
The family had also complained that, when Dr. A. returned to the ward later that evening to pronounce Mrs McCarthy’s death, she did not offer condolences to the family. Dr. A. in her interview could not recall offering her sympathies to the family, she said that she generally would, but also said that maybe she didn’t in this particular case, or that maybe she did “in a general way rather than to each of them individually”, she could not remember. She offered an apology to the family if she did not sympathise with them, or if she had made them uncomfortable in any way following the death of their mother, as it would not have been her intention to do so.
The nurses who were present on the ward at the time Dr. A. attended Mrs McCarthy could not recall, when interviewed, what the Doctor said to the family.
The medical notes show that Dr. M was aware on 24 November (the day Mrs McCarthy died) of the initial result of the x-ray taken that day which showed, as noted by him, “a possible nasal bone fracture but no obvious displacement laterally”. The x-ray was formally reported on 25 November, and showed that there was a fine fracture in the nasal bones but no evidence of displacement. In his interview with investigators, Dr. M. did not recall telling the family about the nasal fracture on receipt of the initial report that day. He explained that his concern at the time was the condition of Mrs McCarthy’s chest, and the necessity to start her on antibiotic treatment. In her submission dated January 2011, made having seen extracts of the draft report, the former Director of Nursing said there was no intention not to communicate that information. She pointed to the practice of informing the family of all adverse events as they occurred. She clarified that it was not a nursing responsibility to convey the diagnosis.
McCarthy’s daughters told investigators that a phone call to them at home on the evening of 25 November, the evening after their mother’s death, caused them great distress. The Ombudsman has established that the Assistant Director of Nursing (now retired) phoned the family that evening, having herself been contacted by Dr. X at about 19.00hrs, about the necessity of transferring Mrs McCarthy’s remains to Beaumont Hospital straight away for refrigeration. The family claim that the Assistant Director of Nursing asked them where Mrs McCarthy’s body was, and they found this very distressing, as they had thought that their mother’s remains had already left St. Mary’s.
Investigators spoke to the former Assistant Director of Nursing. In her interview, she said that Dr. X had phoned her sometime after 18.00hrs asking if she could arrange for the removal of Mrs McCarthy’s remains to Beaumont Hospital. She said that she phoned Mrs McCarthy’s daughter and asked her for the number of the family’s undertaker. She said that she was very upset and disappointed that her mother’s body was still at St. Mary’s. The Assistant Director of Nursing denied having asked where Mrs McCarthy’s body was, explaining that the problem was that Mrs McCarthy’s remains were still at St. Mary’s Hospital and needed to be transferred to Beaumont Hospital.
Nurse F, who made the phone calls about these falls has apologised if her manner upset the family and acknowledged that it would be distressing for the family to hear that their mother had fallen. She said that these falls were also upsetting for staff. The Ombudsman accepts that Nurse F had no intention of upsetting the family. However, the Ombudsman would stress the importance for nursing staff to be sensitive to the anxiety families experience in such situations and that this be reflected in their communication with them.
The Ombudsman accepts that Dr. A. had no intention of upsetting the family and that, at that time she was a junior doctor who was dealing with a dying patient, without the support of a more senior colleague, as would be the case in a general hospital setting. Furthermore, she was not experienced at giving bad news to families and did not have the benefit of a more senior colleague to observe in St. Mary’s, as she was the only doctor in the hospital when she was on afternoon duty there. Nonetheless, the Ombudsman cannot disregard the distress caused to the family because their mother’s actual condition was not communicated clearly to them. Clear communication with the family at this time could have lessened their distress in what was already an extremely stressful situation. It was also insensitive for the doctor not to have offered condolences to the family when she returned to the bedside after Mrs McCarthy had died, as appears to have happened.
Following the Ombudsman’s preliminary examination of the issues raised in this complaint, investigators met with Mrs McCarthy’s daughters. It transpired in that meeting that the family had not been given the result of the x-ray taken on the day their mother died, and that they did not know that she had sustained a fractured nasal bone. The family first heard about the fracture in a meeting with Ombudsman staff. This is a serious failure of communication with the family on the part of St. Mary’s hospital and the medical personnel involved. There were opportunities for the family to be told about this fracture which represented a head injury. Dr. M had recorded the initial x-ray result, including “possible nasal bone fracture” on the afternoon Mrs McCarthy died when the family was present (it was confirmed the next day). Mrs McCarthy’s daughter had attended the hospital the next day, and met with Dr. M to sign the post-mortem consent form, and the family had met with staff of St. Mary’s, including the Consultant Geriatrician and the Director of Nursing, in January 2009. In its statement, the HSE stated that it was unfortunate that the family was not advised about Mrs McCarthy’s broken nose and said that the HSE was told by the Director of Nursing that she was not aware that the family had not been told about it. The Ombudsman has already found, at section 3.6, that the Coroner was not notified of all relevant information in this case.
It is not possible to establish exactly what was said in the phone call made to Mrs McCarthy’s daughter on 25 November 2008. What is clear is that this call was made because of confusion about the logistical arrangements for the post-mortem, specifically, about the transfer of the remains to Beaumont Hospital, and that the call caused the family huge distress. Had St. Mary’s Hospital and Beaumont Hospital liaised with each other regarding the logistics for the transfer, this phone call would not have been necessary.
The HSE accepted the detail in the draft report regarding deficits in communication. It also noted that staff members had apologised. The HSE apologised to the family for the fact that they were only made aware of their mother’s fractured nasal bone during the Ombudsman examination of the case. The Ombudsman is informed by the HSE that a communications module is planned for St. Mary’s Induction Training Programme, and that it will include “updated and reviewed information in relation to end of life pathways, post-mortem procedures, record keeping, and report writing”. The HSE tells the Office that it also intends, on receipt of the Ombudsman’s final report, to disseminate learning on foot of this case, with particular emphasis on end of life communication.
Deficits in communication are implicit in some of the findings in other chapters in this report, but in addition, the Ombudsman makes the following findings that are specific to matters of communication.
The Ombudsman accepts that the nurse in question has apologised to the family, and she welcomes this. However, the Ombudsman finds that there was a failure to communicate in a sensitive manner with Mrs McCarthy’s family about her falls on 22 and 23 November 2008, and that this represents undesirable administrative practice, and is contrary to fair or sound administration as provided for by sections 4(2)(b)(vi) and 4(2)(a)(vii) respectively of the Ombudsman Act 1980.
The Ombudsman acknowledges that the SHO on duty did not set out to offend the family, and that she has apologised to them, and she welcomes this. The Ombudsman also accepts that she was a junior doctor at the time, working alone and without the guidance of a more senior colleague. However, she finds, having considered the evidence, that on the balance of probability, she failed to engage with the family and to communicate clearly with them about their mother’s condition, when she attended her approximately an hour before Mrs McCarthy’s death. This led to them being confused about their mother’s actual condition and prognosis. The Ombudsman finds that this represents undesirable administrative practice, and is contrary to fair or sound administration as provided for by sections 4(2)(b)(vi) and 4(2)(a)(vii) respectively of the Ombudsman Act 1980.
The Ombudsman finds that there was a failure by the Dr. M to relay important information to the family about their mother’s condition (i.e. the fact that she had sustained a nasal fracture on the day before she died), despite several opportunities to do so, most recently during the complaints process. The Ombudsman finds that under the Ombudsman Act 1980, this represents undesirable administrative practice (4(2)(a)(vi)), and was contrary to fair or sound administration (4(2)(a)(vii)).
It is not possible to establish what was said in the phone call made by the former Assistant Director of Nursing, on 25 November 2008, and the Ombudsman makes no finding on it. However, it is clear that administrative failures by Dr. X in failing to arrange the post-mortem at Beaumont Hospital, dealt with elsewhere in this report, led to the making of the call in the first instance.
In a number of areas related to falls management, record keeping was incomplete, For example, the ‘Falls Monitor and Record’ documentation showed a total of two falls (12 May 2008, and 27July 2008) for the duration of Mrs McCarthy’s stay at St. Mary’s. However, incident report forms, combined with medical and nursing notes, show that she was recorded as having fallen a total of six times between 27 July 2008 and 23 November 2008 alone.
Falls reassessment forms were not completed at the standard intervals set down in the policy, and reassessment forms were not completed following falls sustained, as provided for. In addition, nursing notes for Mrs McCarthy should have included a weekly analysis of her falls prevention plan. This did not happen consistently.
Mrs McCarthy’s Falls Care Plans were not dated. The standard form does not have a place on which to enter the date.
The Falls Risk Reduction Care Plan included a check-list of interventions for the patient. Referrals to other Departments, such as Physiotherapy and Occupational Therapy, should have shown the date on which the referral was made. The name of the referring health professional should also have been entered on the care plan. Neither dates of referral nor names of the person referring were entered on Mrs McCarthy’s falls care plans.
The result of these failures in record keeping is that a comprehensive picture of Mrs McCarthy’s falls pattern and falls management could not be obtained by examining the documentation.
In her submission to the Office dated January 2011, the former Director of Nursing, stated “the fact that the completion of the forms does not appear optimal does not mean that Mrs McCarthy did not get appropriate interventions and referrals by nursing staff.” She said that despite minimal areas of non-compliance with policy in completion of the forms, all appropriate interventions were being used.
In the early stages of Mrs McCarthy’s stay at St. Mary’s, there are gaps in the nursing notes for her care. For example, there is a note on 21 September 2007, and the next note is for 12 October 2007 (twenty days between notes). The guidelines from An Bord Altranais state that “Narrative notes should be written frequently enough to give a picture of the patient’s / client’s condition and care to anyone reading them. They should provide a record against which improvement, maintenance or deterioration in the patient’s/client’s condition may be judged”. The Ombudsman was told by the former Director of Nursing that, following a review of record keeping practice, a weekly summary note of the patient’s condition is now required, as a minimum.
Despite the fact that Mrs McCarthy was to have been monitored for pain following her fall on 17 November 2008, there is no nursing note for 18 November 2008.
There were periods when no medical note was made of Mrs McCarthy’s condition. There was one period where, with the exception of a visit by an optician, there was no entry in the medical notes (9 July 2008 to 28 September 2008. Seen by an optician on 13 September 2008). When asked about this, and about whether there would be a review of medication within that period, Dr. M. said that the Doctor reviewed patients on the ward. If a patient was stable then were deemed not to require a formal review and no note was made on the medical file. If a patient required review, a note was made.
At times in the medical notes a record is made of the fact that the doctor in question spoke to the family and explained Mrs McCarthy’s condition to them. However, on the day Mrs McCarthy died, there is no record in the medical notes of Dr. A. having explained Mrs McCarthy’s condition to her daughters who were present. In her interview, Dr. A. said that, based on her medical plan, and the fact that the daughters were there at the time, she imagined she would have talked them through it. However, in the absence of a note to this effect, it is not possible to establish that this conversation did take place, in circumstances where the family says that it did not.
Dr. M. did not record any conversation he had with Mrs McCarthy’s daughter about the post-mortem and donation of brain tissue to the brain bank. In the absence of such a record it is not possible for him to demonstrate that the family was adequately informed. This is complicated by the fact that a separate consent form for the brain bank, which may have contained further information, was not provided to the family.
There were no records of Mrs McCarthy’s case at the Department of Pathology, Beaumont Hospital, despite the fact that a member of the mortuary staff was aware of the case and had phoned Dr. X at home regarding the transfer of the remains.
Records related to Social and Recreational Therapeutic Activity were few in number. The form which the Hospital says is an assessment of Mrs McCarthy, on admission, for suitable activities, was incomplete. There were no detailed assessments or care plans for Mrs McCarthy in this area.
The Occupational Therapy Manager states that her Department was involved in Mrs McCarthy’s care, but that its file for her cannot be found. There is no record in the nursing or medical notes of an Occupational Therapist having been involved in assessing or treating Mrs McCarthy.
Good record management is recognised as underpinning professional practice. An Bord Altranais, in its guidelines on recording professional practice, says that good record keeping is essential to document care, to the planning and provision of care, to facilitate communication between all members of the healthcare team, as well being essential for communication with the patient and the patient’s family. (An Bord Altranais, Recording Clinical Practice: Guidelines to Nurses and Midwives (2002).)The guidelines also acknowledge that good records are essential documentary evidence for an evaluation of the care provided, and that they are essential to professional learning and development in a number of areas including clinical audit, ‘debriefing of patients and clients’ and in dealing with complaints. The Medical Council, in its Guide to Professional Conduct and Ethics states that doctors have a duty to maintain accurate and up-to-date patient records.
When it comes to the examination of a complaint by the Ombudsman, the medical, nursing and allied health professional notes are critical, along with interviews with the parties to the case, in establishing what did and did not happen.
In response to the draft report, the HSE stated that St. Mary’s engages in continuous quality improvement and ongoing audit of documentation. The Ombudsman is told that weekly summaries of the condition of residents is now required in the nursing notes, and the Ombudsman’s attention was drawn to the fact that even where there were gaps in nursing notes, other daily records were kept which gave an indication of the residents’ status. The Ombudsman’s attention was also drawn to the fact that St. Mary’s is a nursing home and not an acute hospital.
The Health Act 2007 (Care and Welfare of Residents in Designated centres for Older People) (Amendment) Regulations 2010 provide, at regulation 4(g), that a record of falls and of treatment provided to residents shall be kept by such centres. While the regulations were not in place when Mrs McCarthy was resident at St. Mary’s Hospital, they represent best practice in the area which was generally accepted at the time. There were deficits in record keeping in Mrs McCarthy’s case in the following areas, as detailed above:
The Ombudsman finds that the failings in record keeping identified are contrary to fair or sound administration (section 4(2)(a)(vii)), under the Ombudsman Act 1980.
In response to the Ombudsman’s Draft Investigation Report, where the HSE responded to particular matters raised, it also provided information on various developments at St. Mary’s hospital since Mrs McCarthy was resident there. These include:
The Ombudsman was told that a number of facilitators (20 to 31 May 2011) have participated in an end-of-life care training initiative, developed by the Hospice Friendly Hospitals Programme, entitled “Final Journey”. Members of staff have also completed courses in palliative care and bereavement studies, and a palliative care in-service training programme has been developed.
A Hospice Friendly Hospitals Committee is in place at the hospital, and it works to reflect on practice and to improve processes. As a result of its work, an End of Life Support Service is now available for families, and information leaflets have been developed.
The Ombudsman was told that to date 5 nurses and an Occupational Therapist have been trained in Dementia Care Mapping, and that any resident with a diagnosis of cognitive impairment/dementia is now referred to a trained person for completion of a dementia care map. A behavioural assessment is also completed. During 2011, in-service courses were held at St. Mary’s on “Caring for the Person with Dementia”.
In May 2009, a Gerontological Nurse Specialist commenced work at St. Mary’s. The Ombudsman was told that her work “prioritises areas of assessment, continence promotion, hygiene, pain management and other issues”. She can also provide specialist advice and guidance to staff.
In 2009, a Residents’ Recreational Centre was opened in a building which was refurbished for that purpose. The Ombudsman was told that this resource is “well utilised by the Recreational Therapy Department to enhance the quality of life for those who live in St. Mary’s”.
The HSE has accepted the Ombudsman’s finding that in Mrs. McCarthy’s case the hospital’s falls prevention policy was not complied with and that formal reassessments of risk were not carried out. The Ombudsman recommends that a system of regular audit be put in place at the hospital to assess, at regular intervals, practice in falls prevention against the policy and procedure in place. This audit would include an assessment of individual residents’ falls prevention care plans.
It would appear from this case that staff were reluctant to look for extra staffing resources for the supervision of Mrs. McCarthy, and that this reluctance was based on a perception that resources would not be made available, rather than on an assessment of her need. The Ombudsman recommends that a system be put in place which allows for the formal consideration of extra supervision where nursing staff are concerned that current levels are inadequate, and that all staff are made aware of the system and criteria to be considered. The system might include a formal written request to the Clinical Nurse Manager on the ward which could be escalated to the Director of Nursing as necessary. Any decisions on such requests would be documented on the patient’s file.
The Ombudsman recommends that St. Mary’s put a procedure in place for the recording of information provided to the Coroner and that the procedure, which may take the form of a comprehensive checklist, as well as narrative, be adhered to in all cases. The form should be signed by the Doctor providing the information, and a copy placed on the deceased resident’s file. Any records of conversations with the Coroner’s Office should comprise a level of detail which would allow all of the information relayed to him to be established. Consideration could be given to the inclusion of a declaration to the effect that the information provided to the Coroner is complete and comprehensive. The Ombudsman recommends that this procedure be developed within 8 weeks of the date of this report and that, on completion, a copy be provided to the Office of the Ombudsman.
The Ombudsman recommends that St. Mary’s finalise the development of a protocol and procedure to deal with requests from families for hospital post-mortems as well as any related post-mortem procedures which may arise from time to time (for example, Brain Banking). Such a procedure should include provision for briefing of the family by the appropriate hospital personnel, as well as safeguards for informed consent. Steps should be taken to ensure that medical and nursing staff are aware of the procedure and in a position to advise families about it. The Ombudsman recommends that this be finalised within 8 weeks of the date of the Ombudsman report, and, on completion, that a copy be provided to the Ombudsman’s Office.
The Ombudsman recommends that the hospital audit the daily care records of residents at regular intervals to ensure that they reflect accurately the care given.
The Ombudsman recommends that St. Mary’s introduce a procedure for the comprehensive assessment of the needs of residents with regard to social and recreational therapeutic activities, to include their ability to participate in these. She further recommends that the tool provide for the reassessment, at regular intervals, of the needs in this regard, with particular regard to residents with dementia. The Ombudsman recommends that this procedure be finalised within 8 weeks of the date of the Ombudsman’s report, and, on completion, that a copy be provided to the Ombudsman’s Office.
The Ombudsman recommends that St. Mary’s review safety on Rhiannon ward, in particular the exit and entry system at the outer door.
The Ombudsman recommends that St. Mary’s provide a suitable appropriately furnished area, adjacent to Rhiannon ward, available for private visits, and that these areas be clearly identifiable to residents and visitors alike for their use.
St Mary’s has told the Ombudsman that a module on communication is planned for its Induction Training Programme, which will include dealing with end of life issues. It is also intended, on receipt of the Ombudsman’s final report, to disseminate learning arising out of this case with particular emphasis on end of life communication. The Ombudsman recommends that this module is developed as a matter of urgency and that provision be made in it for its delivery to all non-consultant hospital doctors who are working at St. Mary’s, in whatever capacity.
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The complaint arises from the care and treatment afforded to Mrs Mary McCarthy (deceased), formerly of [address], while resident at St. Mary's Hospital, Phoenix Park, that is, from 7th June 2007 until her death on 24th November 2008. The complaint, which is made by Mrs McCarthy's daughter, on behalf of the family, relates to Mrs McCarthy's treatment generally, to her care and treatment in the weeks before her death, and, in particular, to her treatment on the day of her death. The complaint also raises issues related to a request for a post-mortem and the donation of brain tissue to the Brain Bank at Beaumont Hospital. It is contended that both Mrs McCarthy and her family suffered adverse effect due to deficits in the care and treatment of their mother, and to actions of the hospital following her death, and that such adverse effect arose out of one or more of the grounds set out in section 4(2)(b) of the Ombudsman Act 1980 (copy attached).
There are a number of issues arising in this case including issues related to the following: