Investigation Report

Published  July 2005

A Report by the Ombudsman in relation to a complaint about the care and treatment of a patient at Sligo General Hospital

An investigation under Section 4(2) of the Ombudsman Act, 1980 against the North Western Health Board (now Health Services Executive -North Western Area)


The complaint which gave rise to this investigation report, was made to me by members of a family, whose father died while he was a patient in Sligo General Hospital in January, 2000. It relates to the care and attention he received during that time.

As Ombudsman, I am very keen to ensure that patients in public hospitals are treated with dignity, respect and sensitivity, and that complaints from patients or their families are handled in a proper, fair and understanding manner. This report provides answers to many of the questions raised by the family following the death of their father while in hospital care, and criticises the manner in which the former North Western Health Board dealt with their subsequent complaint.

A point often made by complainants is that hospitals should learn from their past mistakes so as to ensure that other families do not experience similar problems. It is in this context that I have decided to publish this report, so that it will be available to the public in general, and to the newly formed Health Service Executive in particular. I hope that the issues raised and lessons learned will be taken on board by the wider public hospital system.

Emily O'Reilly

July 2005

The late Mr X was admitted as a public patient to Sligo General Hospital (hereinafter called SGH) complaining of back pain and shortness of breath on Friday, 5 January, 2000 at 16.30 hours. This followed a request from his General Practitioner, who telephoned SGH and arranged to have Mr X admitted via the Admittance Office. Mr X was admitted under the care of the Acting Consultant Physician to the Medical North Ward, the Hospital's acute medical ward. Mr X remained as a patient in SGH until Sunday morning 7 January, 2000 when he suffered a cardiac arrest and died.

The family of the late Mr X contend that adequate medical care and treatment was not provided for their late father at SGH during that period. Following their father's initial admission to the ward he was waiting two hours before he was seen by a doctor. According to the family, a doctor came only after they had made a number of enquiries at the nurses station as to the delay.

On the morning of Saturday 6 January, the family contend that they received a distressing phone call from their father. When they arrived at the hospital, approximately one hour later, their father was still sitting beside the telephone on the corridor, in a wheelchair, cold and disorientated, and wearing only his vest and pyjama bottoms. They helped him back into bed and spoke to the nurses regarding his breathlessness, mobility and the fact that he appeared to be in pain. There were two solpadol tablets on top of their father's locker and the family gave them to him, having consulted with the Receptionist (Ward Clerk) on duty at the desk whom, they alleged, said that if the tablets were on the patient's locker, they were for him.

After lunch on Saturday, 6 January, the family say that they spoke to an Intern, who indicated that there were no major worries regarding their father's health and that he would probably be on tablets for his condition. The Acting Consultant Physician subsequently told the family that the Intern was not qualified to make such a statement since he was just out of medical school and had no experience on the wards.

Later in the afternoon of 6 January, Mr X complained of a severe pain in his left leg. The family contend that they called the nurse on duty who promised that a doctor would come and examine their father. When no doctor came the family contend that a daughter of the deceased went out to see what was causing the delay and found the same Intern at the nurses station fixing a swivel chair. He subsequently examined Mr X but, at that stage, the pain had eased since the nurse had rubbed his leg and elevated it onto a chair. They assert that the Intern was dismissive in his approach and had adopted a "what would you know attitude" towards them when they asked him about their father's medication. The family was concerned to note that, on inspection of the medical notes following their father's death, there was no record of the Intern's examination. The intervention had, however, been recorded in the nursing notes.

The family was concerned that, whilst their father had been restricted to a fluid intake of 800 mls per day, no fluid restriction sign had been placed over his bed, and neither Mr X nor his family were made aware of this restriction. They also state that their father never received oxygen despite the fact that the administration of same was prescribed in the medical notes. In addition, while Mr X's blood pressure was taken on three occasions during his admission, it had not been taken on the morning of his death.

The family complained that a male patient in the bed opposite their father was in a constant state of undress, which caused them and Mr X's grandchildren some embarrassment. This patient was semi-nude from the waist down on both days they attended the hospital. The family contend that they brought this matter to the attention of nursing staff, whom they say enquired as to whether the family had drawn the curtains around this patient's bed.

At 08.08 hours on Sunday morning, 7 January, a daughter of Mr X rang the hospital to enquire about her father. She contends that she was asked to ring back as the nurses were changing shift. At 08.20 hours she received a call from the hospital to say that her father was very ill, and to tell the other family members to come in straight away. On arrival at the hospital, Mr X's daughter contends that she was met by two nurses who advised her that her father had been found in a collapsed state at 07.50. The family was unable to ascertain who found Mr X and why the cardiac bleep (call to alert the cardiac arrest team of emergency) did not sound until 08.15.

When the rest of the family arrived at the hospital, they were brought into the ward to see their deceased father. The curtains had been pulled around him but he was unshaven. The family contend that when they enquired from the nursing staff as to whether Mr X had received the Last Rites, their question was met with shrugs and apathy. After further questioning by the family, the nurses decided to check the book, and advised them that Mr X had not received the Last Rites. The family then arranged to have their father's Parish Priest administer the Last Rites to him which was done some four hours later. The family complained that the nursing staff seemed to disappear and no member of staff offered their condolences. No member of the medical staff came to speak to them. On leaving the ward, the family say that they were asked to take their father's belongings which, they say, were left insensitively in three black bags under the Christmas tree. When examined at a later stage, the family found a box of disposable gloves included among his belongings.

The family assert that their father had occupied the bed nearest the window in the ward. However, after Mr X died a daughter of the deceased noticed that her father had been moved to the bed next to it. No explanation has ever been given as to why this had happened.

Following Mr X's death, the family met with the Acting Consultant Physician, the General Manager, the Director of Nursing, the Sister in Charge of the ward, and the Consumer Services Officer. The General Manager promised that the shortcomings which they experienced in relation to the care and treatment of their late father would be pro-actively addressed. The family was promised a written apology within one week, but this never materialised.

In view of their dissatisfaction with SGH's response, the family complained to me in the matter. On 4 October, 2001 my Office wrote to the North Western Health Board requesting a report on the family's complaint.

Response by the North Western Health Board

The Board's response to the notification of the complaint was to write a letter of apology to the family. This response failed to satisfy the family who could not understand how it had taken so long for the Board to issue this letter of apology. They also felt that it did not address the issues they had raised, and did not outline in any detail what steps the hospital had taken to ensure that similar complaints of this nature would not be received in the future. The family wanted an apology for the medical and nursing shortcomings and details of the changes in procedures as a result of their complaint, including revised training and education of staff. They considered the Board's response to be trivial and minor in relation to the serious issues which they had raised.

Following further correspondence from this Office, the General Manager wrote to the family in April, 2002 indicating that he had re-examined all of the issues and concerns raised by them. The letter explained how the Intern had just completed his medical degree when he had been assigned to the Medical Team at SGH. It also indicated that the Intern, who no longer worked for the Board, had been contacted and had stated that it would never be his intention to upset a patient or their family, and had expressed his regret for doing so.

The General Manager explained how the Procedures Manual at ward level had been revised, where appropriate, to take account of the issues raised by the family. However, when my Office sought a copy of the revised Procedures Manual this was not forthcoming. Eventually, in September, 2002 my Office received a copy of the revised "Policy for Last Offices - Guidelines for Nursing Staff", which had only been revised the month previously.

In the course of the examination of the complaint, staff from this Office inspected the hospital's medical records and nursing records pertaining to the late Mr X. Medical notes, created and updated by medical staff record a patient's medical diagnosis and treatment following admission to hospital. Good practice dictates that all medical interaction between medical personnel and a patient is recorded on the medical notes so that each time a member of the medical team examines or reviews a patient, a record is created which reflects all significant changes in the patient's medical condition.

Medical Records:

The hospital's medical notes in respect of Mr X indicate that he was examined by medical personnel as follows:

Friday, 5 January, 2000 - no time recorded but known to be around 18.30 hours- following his admission to the hospital via the Accident and Emergency Department. Mr X was examined by the Intern who noted that he had lumbar back pain twenty years ago, and this was a similar pain radiating into both hips, which affected his mobility. He noted that Mr X had a productive cough with a wheeze.

The Intern made reference to Mr X's hands being swollen and to his abdomen being distended. He recommended that oxygen be provided but did not quantify this in the records.

Friday, 5 January, 2000 - 20.30 hours The Registrar examined Mr X and noted swelling of the extremities, abdominal distension and low back pain of three weeks duration. He observed congestive cardiac failure, the presence of ascites (fluid retention) which were probably secondary to chronic liver disease, and recommended that Mr X be referred for orthopaedic consultation. The Registrar ordered a range of tests to be carried out including routine blood tests, lumbar spine x-ray, ECG, ECHO and abdominal ultrasound.

Saturday, 6 January, 2000 - no time recorded but presumed to be early morning- The Registrar recorded that Mr X had been seen by the Acting Consultant Physician who also observed congestive cardiac failure, chronic liver disease, and requested an orthopaedic consultation for Mr X's back pain. The Acting Consultant Physician ordered that Mr X's fluid intake be restricted to 800 mls daily, that input and output be recorded, that he be weighed daily, and he noted that lab results were pending. A further entry by the Intern on that day indicated that Mr X had been seen by the team on the ward and that he had symptomatically improved. He noted that Mr X's main problem was back pain which he had for twenty years, and for which he had three previous admissions. There were no further medical entries in the records for that day, although the Intern examined Mr X in the afternoon of 6 January following a request by his family to do so.

Sunday, 7 January, 2000 -8.45 am Consultant Anaesthetist recorded that a cardiac arrest bleep was received at about 8.15 am for Mr X, and that the patient was in asystole (patient was without pulse and had no cardiac output). Intubation (tube is passed down the windpipe to provide artificial ventilation) was attempted but unsuccessful and Cardiopulmonary Resuscitation (compressions delivered to the chest wall to keep blood pumping around the heart) was abandoned after twenty minutes as no pulse or heartbeat was present. There is a further entry in the medical records for Mr X dated 7 January, which was initialled, confirming that Cardiopulmonary Resuscitation was stopped after twenty minutes as there was no response to resuscitation attempts. The fluid retention chart for Mr X indicated that his intake of fluid was 760 mls on 6 January, which was within the 800mls limit recommended by the Acting Consultant Physician.

Nursing Records:

Nursing records, created and updated by nursing staff on duty, indicate nursing interactions with a patient, the outcome of such nursing interaction and problems pertaining to patient needs. The hospital's nursing notes in respect of Mr X indicate that the following interactions between nursing staff and Mr X occurred (note - a night entry indicates that the entry was made between 20.00 hours and 08.00 hours; a day entry 08.00 hours and 20.00 hours- the night and day rosters respectively):

Friday, 5 January, 2000 - 16.30 hours Day report noted that Mr X had been admitted to the ward accompanied by his daughter. Also noted that oxygen was planned and medications chartered.

Friday night into Saturday morning - 5 into 6 January, 2000 - no time recorded: Night report noted that Mr X had a chest x-ray in Department which was reviewed by the Intern (no mention of this in the medical records), and that a further dose of I/V lasix was given at 05.25 hours in an effort to reduce fluid retention levels. Observed that Mr X appeared jaundiced. Also noted that the Registrar had reviewed Mr X early morning (no time stated) and that tests such as ECHO, Abdominal Ultrasound and orthopaedic consultation were to be arranged following an x-ray of Mr X's lumbar spine. Noted that Mr X slept for short periods, that he was to be weighed daily and that his input and output was to be recorded.

Saturday, 6 January, 2000 - no time recorded: Day Report- Recorded that Mr X had been seen by the Acting Consultant Physician who placed a fluid restriction of 800mls on the patient. Noted that Mr X was awaiting x-rays of lumbar spine, that he sat out beside his bed for periods but remained short of breath on exertion. The nurse recorded that Mr X's observations were within acceptable limits but abdominal distension still persisted.

Saturday, 6 January, 2000 - (P.M.): The nurse recorded that Mr X complained of pain in the calf of his left leg and was seen by the Intern. Nothing new was ordered as the pain seemed to lessen on Mr X's return to bed.

Saturday, 6 January, 2000 - Night Report -no time recorded: The nurse noted that Mr X was disorientated and found it difficult to get comfortable due to ascites (fluid retention). Also noted that he slept for long periods.

Sunday, 7 January, 2000 - Day Report -no time recorded: The records show that Mr X was found in a collapsed state in bed at 08.15 hours. Cardiac arrest bleep sounded and resuscitation was attempted unsuccessfully. Mr X was pronounced dead at 08.35 hours. His family had been contacted and they signed the consent for a post mortem on their father.

In view of the issues raised in the case, I felt that it would not be possible to resolve the complaint at preliminary examination stage. My Office wrote to the Chief Executive Officer of the North Western Health Board in December, 2002, indicating that I had decided to initiate a formal investigation of the complaint.

Interviews with Staff:

The following nursing, medical and administrative staff were interviewed with regard to the complaint:

  • Ward Sister, Medical North (Clinical Nurse Manager)
  • First Unit Nursing Officer/Services Manager (who resigned from SGH in September, 2001)
  • Second Acting Unit Nursing Officer/Service Manager (who replaced first Unit Nursing Officer/Services Manager from March, 2002)
  • Nurse Practice Development Co-Ordinator
  • Consultant Physician
  • General Manager
  • Consumer Services Officer
  • Medical Intern


Clinical Nurse Manager, Medical North:

This Ward Sister was one of two Clinical Nurse Managers assigned to the Medical Ward who had responsibility for the 30 bed male medical ward to which Mr X had been admitted. She was not on duty on the day in question. She stated that the type of patient admitted to the ward varied from acute respiratory cases, cardiac cases and patients suffering from overdoses. Many of the patients were confused elderly men.

The lay-out of the ward encompassed four (six bedded) cubicles, six single rooms and the nurses station, which was situated beside one of the cubicles which served as an observation unit. In terms of staffing, there were six staff nurses, including the Ward Sister, normally assigned to the ward during the day. At night, there were three nurses on duty who would each have a complement of beds to look after. According to the Ward Sister, staffing levels could be compromised as a result of sick leave and the Nursing Office was informed when staffing levels fell below the number required. The Nursing Office would make every effort to move nurses from other Departments to help out in the medical Department and if this was not possible staff might send disclaimers to the Nursing Office.

The Ward Sister confirmed that Mr X arrived at the hospital at approx. 16.30 on Friday 5 January, 2000, and was admitted to the ward via his GP. He was initially seen by a nurse, but subsequently was examined by the Intern and later by the Registrar. There had been a delay with the Intern assessment. She explained that a lot depended on the availability of a doctor, but that the practice had changed since then. All medical patients who are referred by their GP now go through the Medical Assessment Unit, which is a way of fast-tracking these patients. The procedure is that the GP rings the House Officer on call, in advance, so there is no delay in the patient being examined by a doctor.

The Ward Sister noted that the assessment form had been completed fully in respect of Mr X indicating that he suffered from lower back pain, normal blood pressure, productive cough and poor breathing. She stated that Mr X was conscious and orientated on admission, according to the nursing notes.

The Ward Sister confirmed that the Registrar had ordered routine blood investigations for Mr X together with an ECG, ECHO and Ultrasound. When asked during the interview as to how these requests were transmitted to nursing staff, she explained that the nurses reviewed the medical notes and followed the doctor's instructions.

In relation to the failure to provide oxygen to Mr X and the failure to display a fluid restrictions sign over his bed, the Ward Sister said that according to the admission notes, Mr X's breathing was normal but that he was short of breath on exertion, according to the nursing notes of 6 January, 2000. The Intern indicated that oxygen was required but did not record the specific amount to be administered to Mr X on the medical chart. The Ward Sister said the nurse should have queried this aspect with the doctor. Whilst the level of a patient's blood gases is a determining factor in the administration of oxygen, the precise details to be administered should have been recorded in the medical notes.

The Ward Sister made the observation that the question of oxygen was not followed through by any of the other medical staff involved in Mr X's care. In relation to the fluid restrictions sign, she said that the intake/output chart clearly indicated that this was being measured. It was the responsibility of the nursing staff to put up the sign for same. In this case, she could not say whether there was a sign over the patient's bed or not.

After the complaint was made to the hospital by the family, the Ward Sister said that she met with all of the nurses on duty during Mr X's stay and discussed the complaint with them. She said she went through each point individually with them in a very serious manner. In the normal course of events, she said that every complaint was treated in a serious manner, that one would try to defuse the situation, apologise for any short-comings and seek to ensure that the nature of the complaint did not occur again.

The Ward Sister agreed that it was unacceptable for a relative to be asked to ring back because the nurses were changing shift. She also said that there was no malintent in leaving Mr X's belongings beside the Christmas tree. The tree was near the reception area and a prominent place to leave such belongings so that the family would not go home without them.

In relation to the Procedures Manual, the Ward Sister explained that the "Royal Marsden" was the guide for all clinical procedures, which was updated from time to time, and which explained how these procedures were to be effected. There is also a Professional Code of Conduct which is provided to all newly qualified nurses by An Bord Altranais which guides the nursing profession in relation to general conduct.

In relation to the issue raised by the family regarding their father being left in the corridor for almost an hour in his vest and pyjamas, the Ward Sister accepted that this should not have happened. She said that she had brought this matter to the attention of the nursing staff on duty, but no explanation was put forward as to why it happened and there was no recollection of this occurring. She said that sometimes there were not enough clothes for patients and this was brought to the attention of Laundry. She said that there was nothing in the manual to direct nurses on this issue - there were some very confused agitated patients in the ward who would try to remove their clothing but efforts had been made to ensure that they were fully clothed by constant supervision and attention.

The Ward Sister indicated that arrangements whereby medical staff made themselves available to speak to families were ad hoc in nature. There would normally be two House Officers and up to two Registrars available around the hospital at any one time. The nurses would often ask the doctors to talk to relatives, and they would also inform relatives that they could talk to the team in the morning time.

In relation to the issue of the administration of medication to Mr X, the Ward Sister said that a Receptionist should not have advised the family in relation to medication, but should have referred the family to the nursing staff. She explained that if a nurse signed for the drugs for a patient, she should wait until the tablets had been ingested. Otherwise, she should take them away until the patient was alert and able to take the tablet. The onus was on the nurse to ensure that all tablets were taken which is the correct procedure in the administration of drugs. She could not say why the tablets had not been taken by the patient.

The Ward Sister indicated that the Intern had prescribed medication for Mr X to be taken on 6 January at 06.00, 14.00 and 22.00 and also on 7 January at 06.00. In relation to the morning of 7 January, the Ward Sister said that there was no temperature or blood pressure recordings in the nursing notes for Mr X, but according to the Drug Administration Sheet the drugs were administered on that morning.

When asked as to whether there should have been such recordings, the Ward Sister said that Mr X's blood pressure was a little low but within normal limits and that there were only two temperature readings taken on 6 January. She said that blood pressure and temperature were normally taken at 09.00-09.30 depending on the acuteness of a patient's condition or if the patient was sleeping.

The Ward Sister confirmed that the nursing shift changeover occurred between 08.00 and 08.15. The amount of information provided to callers could be scant at that time depending on who actually rings. However, she accepted that Mr X's daughter should not have been told to ring back, but could have been advised as to whether her father had a comfortable night, and whether he had any particular needs at that time. The Ward Sister said that she also discussed this issue with the nurses on duty that morning, and there were no written procedures to cover this aspect.

The Ward Sister said that Mr X was found in a collapsed state in bed at 08.15 (according to the nursing notes of that date) and the cardiac arrest bleep was activated (888 dialled). The nurses immediately started resuscitation. The bleep went out to the medical team throughout the hospital and the team responded immediately. The team sought to resuscitate Mr X but he was pronounced dead at 08.35. The family was contacted at 08.20 and requested to come into the hospital. The Ward Sister said it was sometimes difficult to manage these emergencies but that the bed would be curtained off, and the family would usually come to the nurses station first before entering the ward.

In relation to the family's recollection that, on their arrival at the hospital, they were met by two nurses who told them that their father had been found in a collapsed state at 07.50 hours (even though the medical and nursing notes confirm that Mr X was found at 08.15 hours), the Ward Sister said that she did not recall this matter being brought up at the meeting she had with the family. She stated that she had never come across a situation where the bleep was not sounded immediately on discovery of a patient in a collapsed state.

On the issue of the Last Offices policy and the fact that staff did not seem to know whether or not Mr X had received the Last Rites, the Ward Sister said that the priest was normally called in cases of cardiac arrest. There was a Chaplain on call 24 hours a day who attended on a regular basis or would come straight away, if requested. She said that the staff would always sympathise and offer condolences, and she was at a loss to understand why this was not the case as the family alleged. The Ward Sister said that she had discussed this issue with the staff and although the Last Offices policy was only formally published in 2002, it was automatically in place and tea/coffee was always offered to relatives. She said that there was now a written protocol in place which covered all of this.

In commenting on extracts from this Report in draft form, the Ward Sister subsequently wrote to my Office indicating that she had spoken to the Chaplain regarding the issue of the Last Offices. She indicated that the priest had made a note in his diary and recalled being present on the morning that Mr X had arrested and subsequently died. My Office confirmed with the Chaplain that he did administer the Last Rites to Mr X at 8.40 am on the morning of his death.

In relation to the shaving of male patients and the complaint by the family that Mr X was unshaven when he was laid out, the Ward Sister advised that there was a porter assigned to each ward whose duty it was to shave patients on a daily basis, depending on beard growth. She said Mr X should have been shaved if this was required. She suggested that perhaps the time factor did not facilitate this. She confirmed that Mr X had occupied the window bed in the ward and could offer no reason as to why he might have been moved to another bed following his death. The move may have occurred sometime during the night but there was no census of patients available to determine the location of Mr X the evening before or on the morning of 7 January, 2000.

The Ward Sister said that each concern raised by the family had been looked at and the shortcomings addressed with discussions taking place with individual staff members. Open discussion and reflective practice is on-going at ward level, and this is not necessarily documented. The nursing staff were told that these shortcomings must not happen again. The Ward Sister reiterated that the Royal Marsden was the Procedures Manual for clinical matters at ward level, and there was also the Bord Altranais Code of Professional Conduct.

On the question of disciplinary action against members of staff, the Ward Sister indicated that it was the practice to liaise with the clinical nurse manager when issues of concern arose. If considered necessary, a nurse would be referred to the Unit Nursing Officer who would speak to them, arrange retraining or an education programme to support the person, as appropriate. The Ward Sister said that the nurses involved in the care of Mr X were deemed to be competent. In her view, disciplinary procedures were not deemed necessary but the shortcomings were brought to their attention. She did not feel that the shortcomings identified in this case needed to be referred to the Unit Nursing Officer. The complaint was dealt with at ward level.

The Ward Sister accepted in the course of the interview that there had been a lapse in standards on this occasion and this was unacceptable. However, in her opinion, the lapse was not systemic in nature.

First Unit Nursing Officer / Services Manager:

At the time of the complaint under investigation, this nurse held the post of Unit Nursing Officer/ Services Manager at SGH. Her duties entailed having managerial responsibility (reporting to the Director of Nursing) for the delivery of nursing services in a number of units (medical). Each of the units would be directly managed by a number of ward sisters. She had no direct involvement in the care afforded to Mr X at the material time. She left her position at SGH in September 2001, and to her knowledge her vacancy was not filled immediately.

She advised that the family's complaints had been treated with the utmost seriousness. Each concern had been looked at closely and brought to the attention of ward staff. This had been effected by the Ward Sister directly with the nursing staff. The unacceptable lapse in standards had been highlighted at ward meetings. There were no manuals or procedures to be amended as such. Although it was accepted that there was a serious lapse in standards, she indicated that it was not viewed as a disciplinary issue, or an issue that required direct intervention with any individual nurse or required formal retraining. She said that she considered the hospital's response to the family's complaints to be appropriate. The specific results sought from this intervention was that the same things would not happen again.

Regarding the failure to provide oxygen, the Unit Nursing Officer/Services Manager considered that the issue of the oxygen regime might have been subject to change as a matter of clinical decision. She did accept that greater clarity around this issue would have been desirable. It was her view that the failure to place a Fluid Restrictions sign over Mr X's bed represented a failure in communications. In commenting on extracts from this Report in draft form, she stated that for reasons of patient confidentiality it is not always practice to place such signs over patients' beds. As the Unit Nursing Officer/Services Manager had no direct involvement in Mr X's care she was unable to comment on the absence of any recorded Blood Pressure or temperature interventions on the morning of 7 January, 2000.

In relation to the dispensing of medication, she confirmed that there was an onus on nursing staff to ensure that all drugs administered to patients were taken, and that it would be unacceptable for drugs to be left with the patient to be taken at a later stage.

When asked about patient dignity and respect, she agreed that no patient should be left in the corridor for any length of time wearing only a vest. Similarly, in relation to patients who refuse to leave their clothes on, she considered that this should be "counteracted by nursing staff and absorbed as an issue of dignity and respect". In relation to the bags being left under the Christmas tree, she considered that this was unfortunate occurrence, but had not been done deliberately.

The Unit Nursing Officer/Services Manager outlined how she had sought to pursue the complaint and had written to the Intern after he left SGH, but he, unfortunately, said that he had no recollection of this particular case. In relation to the administration of Last Rites, she said that these should have been arranged and it was unacceptable if they were not. She considered, however, that the primary efforts at the time would have been geared towards resuscitating Mr X.

Second Unit Nursing Officer/Service Manager:

The new incumbent of the post confirmed that she had replaced the previous person as Acting Unit Nursing Officer/ Service Manager in March, 2002. She was not involved in the initial investigation of the complaint following the death of the patient in January, 2000. She explained that the ward sisters reported to her and she, in turn, reported to the Director of Nursing. As part of her job, she was also responsible for service management and, in this context, she reported to the General Manager.

When asked as to whether new nursing staff underwent any induction training or initiatives, and whether any part of their training included patient/family communications, the Acting Unit Nursing Officer/Services Manager stated that a core module on communication constituted part of the Diploma in Nurse Training in SGH. However, she was aware that the curriculum content for the diploma may have been different within other hospitals. She added that communication skills development formed an integral part of the current Degree in Nursing Studies.

The Acting Unit Nursing Officer/Services Manager said that Mr X's chart clearly indicated that his fluid intake was to be restricted and that this had been carried out accordingly. However, a sign to indicate this should have been placed above his bed and this is normally done by nursing staff as a matter of course. In relation to the provision of oxygen, this was to be administered, if necessary, according to the doctor. She felt that since oxygen is a drug, it should have been written up as part of a drug cardex. This recommendation is being included now as part of the current revision of the guidelines for the administration of drugs within the hospital.

The issue of Mr X being left on the corridor in his vest for an hour was raised and the Acting Unit Nursing Officer/Services Manager explained that patient dignity and respect was part of training and emphasised to every nurse. She said she was not in a position to determine whether or not this had occurred since she was not involved in the original investigation.

She advised that she was aware that the Consumer Services Officer had given a presentation outlining how complaints should be dealt with, and the issues arising in this case, and others, were highlighted during this presentation. In relation to patient dignity and the gentleman in the bed opposite to Mr X who was seen in a constant state of undress, she said that it could be difficult to maintain the total privacy of a confused or agitated patient in a public ward. Curtains surrounding the bed space of this type of patient must remain open to maintain a safe environment for the patient. She expressed the belief that the events which were complained about were isolated incidents which did not normally occur, and which have not been the subject of complaint since.

In relation to Mr X's belongings being left under the Christmas tree, she said that all belongings were now sent into the Doctor's room, and were passed by the staff directly to the next of kin.

With regard to the various policies and protocols which were available at ward level, she advised that she had asked the Ward Sisters to introduce a new system whereby each nurse would sign off to confirm that he or she had read and understood each policy.

As the Acting Unit Nursing Officer/Services Manager was not involved in the original investigation, she could not offer a possible explanation as to why Mr X might have been moved from the window bed to that next to it, on the morning of his death. She said that it was not the practice to move a patient from one bed to another within the ward, especially when the window bed would offer more privacy rather than a middle bed which would have curtains on three sides.

She advised that acute medical patients are now admitted through the medical assessment unit following phone contact and referral by their GP. Bloods and X-Rays were taken before going to the ward. Otherwise, patients come in through the A & E Dept and are seen by the Medical Registrar.

In relation to the administration of drugs to patients, she confirmed that it was a professional requirement that nurses supervise patients while taking prescribed drugs so as to ensure that medication had actually been taken. The shortcomings in this case had been brought to the attention of ward staff and no similar episode has been reported since that time. A new policy has been implemented for all newly qualified nurses whereby they are supervised by a senior nurse when dispensing drugs for the first six months.

She confirmed from the records that Mr X had his observations taken at 22.00 hours on the Saturday night, and stated that it may not have been necessary to do them again early morning if he was sleeping. Medication and observations were normally completed after breakfast so that patients could sleep and that tablets were not taken on an empty stomach.

In relation to induction training for junior doctors, she advised that such training only covered the hospital in general and that junior medical staff were expected to train alongside more experienced doctors and learn from them. The Senior House Officers and Registrars were normally available or on call if a junior doctor was in any doubt as to what to do.

The Acting Unit Nursing Officer/Services Manager stated that in the event of proven lapse in standards a complaint would go to An Bord Altranais particularly in respect of serious misconduct. It was the view of nursing management at the time that serious misconduct had not occurred in this case.

Nurse Practice Development Co-Ordinator:

The Nurse Practice Development Co-Ordinator stated that she was responsible for the development of nursing practice within the hospital. She has been involved in monthly clinical updates for all qualified nursing staff who are encouraged to attend, however attendance is not compulsory. She outlined the list of topics which she said had been covered during the period January, 2001 - 2003. These topics included the issue of dealing with complaints. A presentation had subsequently been delivered by the Consumer Services Officer, and it was hoped to schedule more of these presentations to nursing staff in the future. She stated that meetings are held on a regular basis with ward sisters to highlight any inadequacies in the hospital services. The ward sisters in turn meet with staff nurses every month to reinforce protocols at ward level.

As part of the hospital's approach to the organisation of care on the medical ward since the death of Mr X, she said that nurses are now divided into teams. Instead of two nurses caring for 12 patients, one nurse is assigned to six patients, and takes sole responsibility for management of those patients. This practice is being gradually introduced throughout the hospital and is currently in place in Surgical North, Medical North, Medical South and Medical 4 wards.

The rationale behind this initiative is that the patient/relative will know the nurse delivering the nursing care, the nurse gets to know her/his patients and plans the individual care with the patient. This improves the lines of communication with the patient/relatives. The nurse takes full responsibility for the nursing care of her/his group of patients.

In relation to the revision of procedures at ward level, she confirmed that the Policy for Last Offices which covers all aspects of a range of religions would be available in the near future, and she subsequently provided a copy of same.

The Nurse Practice Development Co-Ordinator also indicated that it was the practice for each Ward Manager to draw up a statement (Philosophy of Care) which governed the ethos or approach taken by that particular ward. (Such a statement referred to the aim of hospital staff to provide the highest standard of holistic and individual care to each patient, and to strive to deliver patient centred care). It was her opinion, however, that a patient centred approach came through one's training.

Consultant Physician:

The Consultant Physician clarified that the medical team consisted of the Consultant, a Registrar (on call) and two Junior Doctors (SHO/Intern). He advised that "on-call" meant available on the premises. He recalled how Mr X was admitted to the hospital via his GP on 5 January, 2000 and was seen by the Intern and also the Registrar. He said that admissions were normally made through Casualty or through the Medical Unit, but if a patient was very ill then a high priority would be accorded to him or her.

The Consultant explained that the admissions procedure had changed since this case, and acute medical patients referred by their GP are now fast-tracked through the Medical Assessment Unit. There is relatively little delay in a patient being seen by a doctor.

In relation to Mr X, the Consultant recalled that he was a seriously ill man on admission. He said that the post mortem findings tallied with the findings of the clinicians attending him in that there was fluid retention in all parts of his body, indicating liver disease. However, it was not expected that he would die so suddenly. The Consultant indicated that the ECG carried out did not indicate that Mr X required acute monitoring.

When asked why information regarding Mr X's serious medical condition had not been imparted to his family, (they had spoken to the Intern who had said that Mr X would probably have to take medication long term) the Consultant agreed that the Intern should not have said this and that he, the Consultant, had apologised to the family in this regard. He explained that if death was imminent either the Consultant or the Registrar would speak directly to the relatives. He also advised that an Intern should not attempt to furnish a detailed explanation of a patient's medical condition to a family.

In relation to meeting with the family, the Consultant said that neither he nor the Registrar had been approached by any member of the family to discuss their father's condition. When asked whether there was a protocol in place surrounding the provision of information by interns, he advised that it was very much a common sense thing. If an intern is asked, he or she can provide information regarding an obvious diagnosis, but is not qualified to furnish a detailed account of a patient's medical condition. With regard to the availability of consultants to discuss a patient's condition with relatives, the Consultant pointed out that most consultants start their ward rounds early in the morning, which provides little opportunity for relatives to meet with them. If relatives were present, at that stage, consultants would speak with them. Otherwise, family members could ask the secretary or the nurse in charge to arrange an appointment for them.

When asked as to how a doctor's request for oxygen or fluid restrictions were put into operation, the Consultant said that if nurses were given instructions by a doctor to provide oxygen or to enforce fluid restrictions, they will do so. Instructions to this effect can be given either verbally or in writing to nursing staff. He confirmed that the x-rays ordered were done on admission but that the echocardiography was not considered immediately necessary. He also said that blood pressure and temperature checks were matters which were determined by the nurses.

In relation to the Intern it was pointed out that the family had asked that their father be examined as he was complaining of a severe pain in his left leg. They pointed out that the Intern did eventually attend to their father, but there was no entry in the medical notes to indicate this. The Consultant confirmed that every intervention should be noted or brought to the attention of the Registrar at a later stage. He also confirmed that there was no formal training in relation to note taking for Interns at SGH. He said that student doctors spend time observing procedures on the wards, which is a form of "learning by doing" for them. They also learn how medical information is passed to relatives by observing the Registrar or Consultant communicating such information.

With regard to morbidity conferences, the Consultant said there was no formal system in place, but that it was not uncommon for a death to occur on a medical ward. He said that doctors would get together and discuss cases outside the ward area in relation to how ill a patient was, or how he or she was progressing. He explained that if the death of a patient was anticipated, then there would be no formal morbidity conference. If a death was unexpected then a post mortem would ensue. In this case, he said it was obvious that the patient was ill. The Consultant explained that where a patient died within 24 - 48 hours following admission, the hospital would notify the Coroner as a protocol and a post mortem would be performed. If the diagnosis regarding the deceased was very clear then the Coroner would often agree to issue a death certificate. He said he was aware that a post mortem had been carried out on the late Mr X.

When asked why, after Mr X's death, no member of the medical staff had spoken to the family, the Consultant commented that, generally, if the Registrar or Consultant is in the vicinity at the time of death, he will sympathise with the family. Otherwise, the Consultant will usually write a brief note of sympathy to the family. However, he could not say why he did not write in this case. He said that it should not have happened the way it did but sometimes things do happen which indicate that a break has occurred within the chain of command.

The Consultant was asked whether there had been any changes in protocol as a result of this case. He responded that the number of doctors had increased since 2000, and the number of hours worked by each doctor had reduced. He reiterated that the admission system had improved the way urgent medical cases were treated on admission. He confirmed once again that if a patient was chronically ill following admission, the doctor or consultant would notify relatives but, in this case, the doctors did not expect Mr X to die so quickly. The Consultant expressed his regret for what had happened in this case.

General Manager:

The General Manager outlined that he had overall responsibility for the management of the hospital. A key issue for him was the provision of quality patient services. There was a Hospital Management Committee in place with the following membership - General Manager, Director of Nursing, Clinical Co-ordinator and two Consultant Representatives. The Consumer Services Officer dealt with complaints and claims, Freedom of Information issues, and was involved with consumer forums and groups. The General Manager advised that there were eight individual service areas which involved consumers in an analysis of the services, and how the delivery of same could be improved. These reflect the needs of the patients rather than the providers of the service, and had been introduced since this case had occurred. He said that the Consumer Services Officer liaised directly with him, updating him on the cases and he responded by endeavouring to correct the problems. He said that she provided an analyses of cases on an annual basis but they held informal discussions on a regular basis. Service issues were pro-actively addressed.

The General Manager explained that he, together with the Consumer Services Officer, had met with the family of Mr X on 29 May, 2001 and went through the complaint point by point. However, a meeting with the medical and nursing staff was not held until 9 August, 2001 due to the non-availability of staff over the summer period, and the Board's desire to get key people into the meeting so that meaningful responses could be provided to the family.

It was pointed out to the General Manager that the family wanted an apology and an assurance that protocols and procedures would be revised, and that he had promised them a letter of apology within one week of the August, 2001 meeting. In commenting on extracts from this Report in draft form, he recollected promising a written apology to the family but not specifically within a one-week time frame. When no letter of apology was received the family approached my Office. In responding to this Office, the General Manager said that a Speciality Management Team meeting had been held to discuss the hospital's shortcomings. He wrote to the family on 22 October, 2001, apologising for the manner in which they and their father had been treated. He attributed the delay to the fact that he considered it necessary to clear the draft with the Board's insurers and legal advisers. In commenting on extracts from this Report in draft form, the General Manager subsequently did not agree with this interpretation, but did not offer any elaboration. However, I am satisfied from the records created on the date of the interview with the General Manager that this attribution is, in fact, correct.

On the issue of the administration of oxygen to Mr X and the fluid restrictions sign, the General Manager acknowledged that there had been communications problems with regard to these issues. He stated that the Specialty Management Team had flagged these various issues, and they now formed part of the modular training (degree programme) for every student nurse. He also said that the range of documents on procedures and policies at ward level including infection control, protocol following the death of a patient etc., were revised and reviewed on a regular basis.

The General Manager understood that the family was unhappy with the second letter of apology dated 4 April, 2002 due to the lack of detail regarding the measures taken by the hospital to avoid a recurrence of their situation. He felt, however, that he had given the family the assurance they wanted in his first letter and did not see the need to go through each issue point by point given the work that the Unit Nursing Officer/Services Manager had done. In commenting on extracts from this Report in draft form, the General Manager stated that at the time of his letter dated 4 April, 2002 it was his understanding that appropriate revisions had been made to the Procedures Manual.

The General Manager confirmed that where a Solicitor was involved in any particular case that the agreed procedural arrangements with the Boards Solicitors and Insurers is that they would be consulted in relation to that particular case. There was nothing in his letter of 22 October, 2001 which he would change to any great degree, the family had raised valid issues and the hospital was found wanting.

As General Manager, he said that he had admitted that the hospital failed to provide a quality service on this occasion. He said that the issues raised formed part of the on-going in-house training for nursing staff. He mentioned that the Nursing Practice Development Unit Co-Ordinator had been reviewing all the Procedures Manuals at ward level. There was a range of manuals at nursing stations setting out various procedures and these were reinforced during training. The Last Offices was the only manual which needed to be formally revised and this was completed in August, 2002.

The General Manager was concerned as to how the hospital could repair relations with the family in order to bring closure to the case. The family was of the opinion that the hospital had not taken their complaint seriously. He was adamant that the hospital did not trivialise their complaint in any way and took it very seriously at all times. In commenting on extracts from this Report in draft form, the General Manager made the following statement - "By way of general comment, I wish to state that during my time as General Manager at SGH that my overall aim was to ensure the provision of the optimum level of quality services possible within existing resources. At all times I wished the central focus to be the patient and where the Hospital was found wanting in the provision of services that the necessary action was taken to correct any shortcomings in the future provision of services. I would certainly hope that this was reflected in my dealings with Mr X's family".

Consumer Services Officer:

The Consumer Services Officer explained that her job at SGH involved dealing with Freedom of Information requests, Routine/Administrative access requests, the Co-ordinating of incident forms for the Insurance/Finance Section, Co-ordinating of litigation claims against the Board and dealing with complaints. She is also Team Leader for the Sláinte Radio Show, a health information programme researched, compiled, recorded and presented by NWHB staff in association with North West Radio. She outlined that she, together with one clerical officer, handled a workload which consisted in the previous twelve month period of approximately 70 complaints, 130 FOI requests, 200 routine/administrative access requests, approximately 200 Incident forms, and almost 140 general queries that required written replies. The workload involved in the co-ordinating of the litigation claims was ongoing, as queries arose, and was difficult to quantify. She was also involved with six consumer panels (Young people in hospital, Elderly in the Community & Hospital, Dermatology Services, Cardiology Services, Outpatient Services and Maternity Services).

The Consumer Services Officer outlined the details of the Board's regional complaints procedure and the nature of the associated complaints database. The procedures were designed with a view to the resolution of complaints locally, within a service, e.g. by reference to the Ward Manager or the Service Manager.

The Consumer Services Officer said that she had not received a request from the Coroner's Office for information on this case or for a copy of Mr X's chart prior to 18 December, 2000, although the Gardaí in Sligo claimed to have issued such a request to the Administrator in October, 2000. She stated that she had herself responded immediately to the request on 19 December, 2000.

In relation to meeting with the family, the Consumer Services Officer said that she, together with the General Manager, had met with the family on 29 May, 2001. This meeting was arranged following the receipt of a letter by the General Manager from a daughter of Mr X on behalf of the family. At this meeting the Consumer Services Officer documented the family's complaints and these were then forwarded to the medical and nursing staff. A further meeting was held with h