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Care and treatment of a patient and his family
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A Report on an Investigation by the Ombudsman in relation to a complaint about the care and treatment of a patient and his family at Mid-Western Regional Hospital, Dooradoyle, Limerick.
The daughter of a 61 year-old man, who died while in the care of the Mid-Western Regional Hospital, Limerick, complained to my Office about the Health Service Executive. Some days after admission to hospital for investigation and treatment of a stroke, her father fell from his hospital bed and suffered an 8cm laceration to the back of his head, a broken tooth and cuts to his tongue. His condition deteriorated and he died two days later. My complainant was unhappy with many of the actions of the HSE before and after her father’s death. She was particularly concerned that a post mortem examination was not carried out on her father's remains and that the family was therefore left not knowing whether he had died from his admitting medical condition or from the fall itself. The HSE did not notify the coroner until 2 weeks after the man’s death, but the coroner then conducted an Inquest. The man’s daughter asked my Office to investigate her complaint about the actions of the HSE.
My investigation involved interviews with thirteen clinical and administrative HSE staff and an extensive examination of medical records, nursing records, other hospital and HSE records and policies. The investigation sought to establish what happened to this man in his final days and whether there was any maladministration involved in relation to his care and the treatment of his family.
My examination found that much of the care afforded to the patient was of a high standard, but it also uncovered unacceptable failings.
This man had suffered a bad fall in the middle of the night. Given that he had several serious risk factors for falling, my Office examined what actions the HSE had taken to assess his danger of falling and what actions they had taken to minimise that risk. My investigation showed that the hospital had not complied with its own policy on the assessment of risk for falling, or the measures to be taken to prevent falls. While some efforts had been made, these were inadequate and not in keeping with policy. It was not possible for me to ascertain with certainty whether there was a functioning call bell on the patient's bed before he fell, something many patients rely heavily on. The family alleged that there was no call bell in place but this was disputed by nursing staff. Maintenance records for the call bells on the ward were available for adjacent months, but not for the month in question in this case. I also found no evidence to clarify whether the use of bed side rails/cotsides had been properly considered for the patient; in fact, conflicting evidence was presented as to whether they were in use.
I found that the hospital failed to carry out a postmortem examination, in line with hospital policy, or to advise the family in this regard. I found that the hospital failed to advise the coroner of the patient's death in a timely fashion. While the hospital had eventually notified the coroner, after the family had raised their concern and gone to An Garda Síochána, and the Hospital had admitted to this failing, I saw no evidence that appropriate measures had been taken by the hospital to prevent such failures from recurring. Specifically, the patient died at the weekend when his admitting consultant and team were on leave. Although he was considered to be dying on the Friday, some hours after an incident report had been sent to the Risk Management Department describing the bad fall he had suffered and the head injury sustained, nothing had been documented or discussed by the medical team about the requirement for a post mortem should he die over the weekend. The junior, on-call doctor who was asked to certify his death, merely did so, and did not query whether his death was related to the fall and head injury sustained fifty two hours previously, or to his admitting condition. By the time the patient’s medical team returned after the weekend, the funeral arrangements were underway. My investigation found, with the support of expert and independent clinical advice from the UK, that it was reasonable for the family to be left with doubt about the HSE’s contention that their father died from the medical condition for which he was admitted and that his death was not contributed to by the fall he sustained while in hospital.
The complaint to my Office had referred to the failure of the hospital to provide the dying man and his family with any privacy or dignity before and after his death. The man died on a busy ward surrounded by other ill patients. After his death, a curtain was pulled around his bed and this provided the only screen between the remains, his grieving family and all the other patients on the ward, as normal ward activities, such as meals and television, continued. The family alleged that they were asked to leave the ward some time after the patient’s death, even though the remains were left on the ward, alone, for several hours afterwards. Due to the absence of official records, it was not possible for me to ascertain with complete accuracy how long the patient's remains were left alone on this busy ward, however, on the balance of probability, it appears that the patient's remains were on the ward for approximately six hours, several of which were after the family had left. While it may not have been possible to provide a private room for this man in his dying hours, I found that there was a failure to alter activities on the ward or to notify catering staff and visitors of the death on the ward, and of the fact that the remains had not been removed to the mortuary.
I found that it was unacceptable that the Medical Certificate of the Cause of Death, required by the family, was only signed 12 days after the man’s death, and only then, because the family called to the hospital and retrieved their father’s medical chart from the ward where he had died and brought it back to the relevant section.
Finally, I found that there was an unacceptable deficit in record management practices in relation to key elements of the care of the patient and his remains by some hospital staff. Some important information had not been documented, some records were missing and changes had been made to records, contrary to established good practice. The poor record management practices limited the evidence available to me for some aspects of my investigation and contributed to some questions remaining unanswered.
When provided with a copy of my draft report and findings, HSE management fully accepted that there was a number of administrative failings at ward management level and system level in the care and treatment of the deceased. The hospital apologised unreservedly to the family for these failures. They acknowledged and apologised for the failure of a number of staff to adhere to the hospital policy and advise the coroner of the death of the patient in a timely fashion. They said that the delay in the notification to the coroner was not intentional and the subsequent adverse effect on the family was deeply regretted.
I welcomed the HSE's positive response to my draft Investigation Report and the wide range of improvements the hospital has agreed to, both before and after receiving it. Detailed in Chapter 5 of the report, these include improvements to record keeping, verbal and written communications; improved falls management practices: improved post mortem practices; development of staff training, staff guidelines and patient information leaflets; and the implementation of an action plan for end of life care in hospitals.
However, notwithstanding these very positive developments, I made the following recommendations in my final report to the HSE. I recommended that Limerick Regional Hospital take steps to:
I also recommended that a member of the senior management team in Limerick Regional Hospital visit the family to apologise, in person, for the shortcomings identified in this report and to explain what action is being taken on foot of the findings and recommendations contained in the report. Finally, I recommended that, to assist in providing a remedy and closure for the family, the findings of this investigation be drawn to the attention of key staff involved in the care of the patient during his stay in the hospital in the period November 2005 to December 2005.
My Investigation Report was issued to the CEO of the HSE in June 2010 and I am satisfied that the HSE has accepted all my recommendations and devised an action plan to implement these in a timely fashion.
Emily O'Reilly,
Ombudsman
December 2010
1.1 Introduction
The complaint which prompted this investigation was made to me by Ms Brown, following the death of her father, Mr Brown, in the Mid-Western Regional Hospital, Limerick, in November, 2005. The woman was unhappy with many of the actions of the HSE before and after her father’s death. She had already complained to the Hospital and was dissatisfied with the response she received, hence, she asked my Office to accept her complaint.
1.2 Role of Ombudsman and Clinical Decisions
The role of Ombudsman in examining a complaint is to consider whether or not a person has been adversely affected by improper, unfair or unreasonable actions or inaction on the part of a public body, in this case the Health Service Executive (HSE). If this is found to have occurred, I, as Ombudsman, will examine whether or not the public body has taken steps to remedy the adverse effect. In addition, I try to ensure that public bodies deal with individuals properly, fairly and impartially.
By law, I cannot consider complaints which relate to persons acting on behalf of the HSE and which, in my opinion, relate solely to the exercise of clinical judgement in the diagnosis or care or treatment of a patient. However, I can examine the administrative actions of healthcare professionals and administrators, taken in the course of clinical work, which do not involve clinical judgements.
2.1 - Statement of Complaint">2.1 - Statement of Complaint
My Office initially carried out a preliminary examination of the complaint. I was not satisfied that the HSE’s review of the complaint (Appendix 2) was sufficiently comprehensive or detailed, and due to the serious issues presenting, I decided to commence an Investigation into the complaint in April 2007, under Section 4(2) of the Ombudsman Act 1980.
The investigation involved examination of medical, nursing, risk management, mortuary and ward records; interviews with hospital staff; liaison with the Coroner’s office; and review of Hospital policies.
To commence the investigation, I wrote to the HSE on 20 April, 2007, with a Statement of Complaint set out as follows:
Background
Mr Brown was a 61 year old man who was admitted to the Mid-Western Regional Hospital, Limerick in October 2005. He was diagnosed with a stroke/ cerebellar haemorrhage. Early in November 2005, Mr Brown was moved to a high dependency medical ward. (This was later corrected by the HSE. Mr Brown was moved to a Medical Ward.) The next day he was visited by members of his family who were pleased with his progress. Later that week, the family received a phone call early in the morning from the hospital advising that Mr Brown had fallen out of bed at 2.15am.
He suffered a broken tooth, an 8cm (3in.) laceration to the back of his head and cuts to his tongue. He subsequently entered into a deep unconscious state and died approximately 52 hours after his fall. Shortly after his death, the family was asked to leave the ward as hospital staff wished to move his body to the Mortuary. However, once the family left the hospital, Mr Brown's body remained in the hospital bed on the busy ward for a further 6 hours before he was moved to the Mortuary.
Statement of Complaint
The complaint is that
2.2 - Interview with Complainant
As part of the complaint examination process, one of my Investigators met with the complainant. The complainant explained that, on the afternoon before her father's fall, Mr Brown was sitting out in his chair and chatting away to his family. He was alert, aware of everyone present and was eating healthily. He was able to stand up, but he was a little unsteady on his feet. He was complaining of a headache.
The next day, the family received a phone call at about 5.45am from the hospital advising them that their father had had a fall. They were advised to come to the hospital.
When they approached Mr Brown's bed, he was awake but sweating very heavily and breathing very fast. He opened his eyes and looked around. Within three minutes however, he started seizing. Dr. Greene, the Specialist Registrar in Medicine who was on-call that night, advised the family on that morning that he had probably had a secondary bleed and that he was most likely dying.
The complainant told my Office that the family was told that their father had climbed out over the end of the bed. However, the family was not advised about the extent of the injuries their father had sustained following his fall. They said that there was no mention of the 8cm laceration to the back of his head, his broken tooth or the cut to his tongue.
The family spent the next 48 hours with their father and were with him when he died. When he died, the curtain was pulled around his bed and the usual ward activities continued.
The complainant told me that, at about 10am, less than two hours after he died, the family was asked by a staff member to vacate the ward. They were told that staff needed to get organised and to arrange for Mr Brown to be removed to the Mortuary. Later, the complainant told me that she was advised by the Funeral Home Directors that Mr Brown's body was left in his bed for over six hours after the family had left the ward. The complainant said that if the family had known their father was lying in the hospital bed alone in a busy ward, they would have arranged for someone to sit with him.
Some time after Mr Brown died, the family told me that the Tea Lady popped her head around the curtain and asked "Is there breakfast here?" The family looked at her in dismay. On seeing the response, the Tea Lady simply said "all right" and she carried on with her duties. The family said that they have no complaints about the Tea Lady, but they felt that Nursing staff failed in their duty to advise callers and other staff members about a death on the ward.
The complainant told my Office that her father's pyjamas were covered in urine from top to bottom when her sister found them in her father's locker in a plastic bag after he had died. The wet pyjamas had been in the locker for more than three days at this stage.
The complainant told me that she wanted answers to her questions. She felt that her father sustained a helpless fall from his bed and she wanted clarification as to whether it was the fall, rather than the medical condition for which he was admitted, which led to his death.
She was not convinced that her father died from the condition for which he was admitted to the hospital.
Given there was no post mortem (see Appendix 3), the family had a number of unanswered questions. They wanted my Office to pursue their complaint and attempt to establish what exactly happened. They also expressed their belief that an exhumation and post mortem of Mr Brown's remains would be the only definitive way of establishing his cause of death. The family told me that they had contacted the Gardaí after Mr Brown’s death and that the Gardaí had taken statements from Hospital staff and contacted the Coroner (see Appendix 4). Later, the complainant contacted the Coroner herself. The Coroner told her that he was informed of the death 2 or 3 weeks after the patient's death. An inquest was held in April 2006, where an open verdict was returned.
About 2 or 3 weeks after Mr Brown died, the complainant needed her father's Death Certificate (see Appendix 5 and Appendix 6). She went into the hospital and called to the Medical Records Department. She was told that there was no record of her father's death on the computer. She was advised to go to the ward. She went to the ward and saw that her father's file was still on the desk at the Nurses' Station.
2.3 - Response from Health Service Executive
The following response was received from the HSE with regard to each point raised in my statement of complaint to them.
2.3.1 - Delay in performing a CT scan on the patient when he was first admitted to the hospital
The HSE said that, when Mr Brown first presented to the Emergency Department, his clinical condition did not indicate that he required an emergency CT scan of his brain. It was decided to admit, monitor and treat him in the Coronary Care Unit on the night of his admission. The HSE said that, further to a consultation with the Consultant Radiologist on-call, a decision was made to wait until the following morning to do a scan, unless the patient's condition deteriorated during the night.
The hospital reported that the medical notes also contain written instructions in regard to monitoring his neurological observations. These notes state that if there was any deterioration in his condition, the patient was to be reviewed by the medical team on call and his treatment altered as necessary. The HSE pointed out that Mr Brown was stable overnight, with the exception of an ischemic change on his electrocardiograph at 7am the following morning.
Dr Red, the Consultant Physician in charge of Mr Brown's care, advised that there was no clinical indication to necessitate an emergency CT scan on the night he was first admitted.
2.3.2 - The patient's fall, or the moments leading up to it, was not observed by any of the five nursing staff on duty.
The HSE said that Mr Brown was a patient in the main ward of Medical Ward X. This is an acute male medical ward with thirty three beds, fifteen of which are in the main ward. It clarified that the ward is not high dependency and is staffed by four staff nurses on night duty.
It said that, for the purposes of care delivery, two staff nurses are allocated to the main ward and two staff nurse are allocated to care for the patients in private and semi private rooms on the corridor. In addition to the usual staff complement, there was a student nurse on placement on the night shift.
The HSE said that Mr Brown was nursed in a particular bed space to ensure he was observed and monitored closely. The floor lights were on to facilitate patients who needed to get out of bed during the night and to provide a light source for observational purposes.
The HSE acknowledged that Mr Brown's fall was not observed as it occurred. However the noise of the patient falling was heard by Staff Nurses Fox and Howe who were both writing reports at the Nurses' Station, which is in close proximity to the ward. Staff Nurse Philpot and Staff Nurse Waddell, Agency Nurse, who were caring for patients in the ward, were both on a lunch break away from the ward. On their return to the ward, they assisted the two nurses who were attending to Mr Brown to lift him back to bed.
2.3.3 - Advising the family four hours after the fall
The HSE explained that, after Mr Brown was found on the floor beside his bed, his immediate needs were attended to, his vital signs (i.e. blood pressure, temperature, pulse and respiration) were measured and the Glasgow Coma Scale (Appendix 7) completed (These were done to monitor his medical and neurological condition). The doctor was also contacted and attended Mr Brown. His Glasgow Coma Scale measurement was satisfactory at 13 out of a possible 15.
It was checked regularly and remained stable until 5.20am when it measured 8 out of 15, indicating a marked deterioration in his level of consciousness. Further to this deterioration, a decision was taken to contact the family.
The Clinical Nurse Manager II on the ward advised that, unless a patient's condition changed significantly or he became gravely ill, it would be unusual to disturb the family in the middle of the night. However, she said that each situation is assessed and, if the situation necessitates ringing the family, then this action is taken.
2.3.4 - Different recordings of the time of the fall.
The HSE acknowledged that there are three different recordings of the time of the fall. The HSE discussed this issue with the staff nurses and it advised my Office that the time recorded is approximate. This is because attending to the patient's immediate needs is the nursing staff's first priority. It explained that every effort is made to ensure that the recording of details is as close as possible to the time of the event.
The HSE made the point that the Incident Report Form was completed by Nurses Howe and Fox who heard the noise and went to Mr Brown's aid, and the Nursing note was recorded by Nurse Philpot who was caring for patients in the main ward that night with Nurse Waddell.
2.3.5 - Skull X-ray not conducted
The HSE confirmed that Dr Red, Consultant Physician, cancelled the skull X-ray following a review of the patient, the morning after his fall.
2.3.6 - Call bell on bed
The HSE said there was a call bell at Mr Brown's bed at all times during his illness. It further stated that staff members ensure that the call bell is easily accessible to all patients and that it is placed depending on individual patient requirements. It also explained that there is a system in place in the ward to check on all fixtures (oxygen, suction and call bell) at patients' beds at regular intervals.
2.3.7 - Failure to advise the family of its rights to have a post mortem conducted
The HSE admitted that the family was not advised of their right to have a post mortem conducted.
2.3.8 - Failure to carry out a post mortem
The HSE admitted that there was a failure to carry out a post mortem on the patient and the hospital acknowledged and apologised for the omission. It said that it was not a deliberate omission, but that it might be explained by the discussion (documented in the medical record) that Dr Greene, the medical registrar on-call on the morning after the fall, had with Mr Brown's family, where they had agreed that the patient was to be kept comfortable and was not for resuscitation. The HSE said that the Medical Intern on Call, when attending Mr Brown after his death, and having noted this discussion recorded in the medical record, may have considered that a post mortem was unnecessary.
2.3.9 - Failure to consider Mr Brown's death at weekly case conference
The Hospital reported that Mr Brown's care was discussed at the weekly meeting; however, it said that minutes were not taken.
2.3.10 - Sometime after Mr Brown had died, the family was asked to leave the ward on the pretext that the hospital wanted to remove his body to the Mortuary. However six hours later, his body was still lying in the bed on the busy ward and had not been moved.
The HSE told my Office that, when a patient dies, every effort is made to ensure families can spend as much time as they require with their loved one. It said that families are asked to leave whilst the remains are being prepared for the mortuary. This usually occurs within the first hour of death. Once completed, families are left to sit with the remains for as long as they wish. The HSE advised me that none of the staff members interviewed could say for certain the time the family left the ward, but it was their opinion that it was unlikely that any of the staff members asked them to leave.
The HSE checked with the mortuary staff and the procedure in 2005 for the reception of remains did not include logging the time. However, it said that this practice has now changed and the time of reception is now logged.
2.3.11 - Visit from Tea Lady
The HSE admits that this incident may have occurred. It explained that the kitchen staff prepare breakfast and serve it accompanied by a nurse or care assistant who oversees the individual dietary requirements of each patient. It acknowledged that the catering staff member may not have been informed that the patient had died. The HSE said that, if this was the case, the hospital apologised and regretted any upset that this action may have caused to the family.
2.3.12 - Advice from the Consultant that their father could have had surgery
This claim was denied by the Consultant.
2.3.13 - Delay by the Hospital in signing the Medical Certificate of the Cause of Death (Appendix 5)
The HSE confirmed that the Death Certificate was signed 12 days after the patient died. The HSE do not regard this as a long delay.
2.3.14 - There was a delay of two weeks in notifying the Coroner of the patient's death
The hospital agreed the Coroner should have been notified the morning the patient died and that he might have ordered a post mortem.
General
As part of the Investigation, my staff interviewed the following individuals; (all names have been changed.)
List of staff interviewed by Ombudsman
| Ms. Fox | Night Nurse, Male Medical Ward |
| Ms Philpot | Night Nurse, Male Medical Ward |
| Ms. Howe | Night Nurse, Male Medical Ward |
| Ms. Harwood | Clinical Nurse Manager (Night shift) |
| Ms. Morgan | Day Nurse, Male Medical Ward |
| Ms. Grant | Clinical Nurse Manager (Day Shift) |
| Dr Red | Consultant Physician |
| Dr Greene | Specialist Registrar, (Registrar on-call on night of fall) |
| Mr Glynn | Senior Anatomical Pathology Technician, Pathology Department |
| Ms. Merrigan | Hospital Business Manager |
| Dr Finnegan | Medical Intern on Call (MIOC) |
| Dr Murnane | Registrar to Dr Red |
| Ms Stokes | Nursing Care Assistant (Day Shift) |
(On the night of the fall, Nurse Fox was allocated to the main ward. Nurse Philpot was off the ward on lunch when Mr Brown fell. Nurse Howe had responsibility for the patients in the private rooms off the corridor; she had no responsibility for the patients in the main ward. Nurse Harwood was the Clinical Nurse Manager during the night shift. )
2.4.1 - Interviews with nursing staff
All interviews with Nursing staff have been summarised into this section under relevant headings.
Mr Brown's condition before the fall
Nurse Harwood (Clinical Nurse Manager, Night Shift) explained that Mr Brown was moved from his original place in the Medical Ward to a place closer to the Nurse’s Station where he could be observed, as staff were concerned about him. When asked to describe Mr Brown's condition, on the evening before his fall, Nurse Harwood said that, when she first met Mr Brown on Sunday, 30 October, his gait was unsteady. She said he was advised to call the nurses if he needed help or if he needed to go to the toilet.
Observation of the Fall
The nurses explained that Mr Brown's bed was visible from the Nurses' Station (Staff from my Office visited the ward and noted that the Nurses’ Station was on one side of the ward corridor, directly across from double doors leading into Mr Brown’s ward. Mr Brown had been moved to the second bed on the left hand side of the ward and this bed was visible from the Nurses’ Station. The distance between his bed and the Nurses’ Station was approx 10 metres). The ward floor lighting was on, the door to the ward was open and the patient's bed light was off.
Nurse Harwood said that there is always a staff presence on the ward during the day, but not always at night time.
She explained that, on night duty, staff are coming and going, changing and turning patients.
Nurse Fox and Nurse Howe were sitting at the Nurses' Station when they heard furniture move and, just as they were getting up to check the situation, they heard a thump. They turned on the light, saw the patient on the floor and got him into recovery position. Nurse Howe confirmed that the patient was on the floor for about 30 seconds before he was attended to. She explained that, as they were writing their notes at the time at the Nurses' Station, they did not actually see the fall.
Nurse Fox said that, following his fall, the patient's eyes were twitching and he was seizing. He had a gash to the back of his head, he had bitten his tongue and his tooth was broken. He was barefoot and his pyjamas were on. They applied a pressure bandage to his head and Nurse Howe stayed with him while Nurse Fox went to get some swabs. There was blood immediately visible at Mr Brown’s head on the floor. He was conscious but not speaking.
Nurses Philpot and Howe advised my staff that the patient's bed side rail was in a down position, while Nurse Fox advised that the bed side rail was in an up position. However, no documentary evidence was produced to support either claim.
Dr Finnegan, the Medical Intern was called and the patient's Glasgow Coma Scale (GCS) signs were assessed by Nurse Philpot (who had returned from her meal break); Mr Brown scored 13/15. Dr Finnegan suggested that the patient needed a skull X-ray in the morning. The four nurses put the patient back to bed and his GCS was observed every 15 minutes. Nurse Fox clarified that none of the other patients in the ward witnessed the fall.
Notifying the family four hours after the fall
Nurse Fox explained that, after his fall, the patient's condition was stable until about 5am. Accordingly, the nurses didn't contact the family. The nursing staff were taking the patient's neurological observations every 15 minutes. The Medical Registrar noted at 5.30am, that the patient's GCS was deteriorating and Nurse Philpot suggested that the family be called.
Nursing staff explained that normally, when a patient falls in the middle of the night and his condition is stable; nursing staff would not ring the family until the following morning. They felt that they took the appropriate action given the circumstances.
Time of the fall
My Office pointed out that there was a difference of 50 minutes between the various times the fall was reported (Hospital and Garda records). Nursing staff generally agreed that the fall happened about 2am and that the times on the Neurological Observation Chart (Appendix 8) were probably the best indication of the time of fall. The first time recorded for these observations was 2.15am suggesting that the fall happened just before then. They stressed that, in emergency situations, staff tend to a patient's needs first and then document the actions at a later stage.
Nurse Howe explained that, while she completed the Incident Report Form, she didn't enter the time of the fall on the form, she said that this was done by the Hospital's Business Manager, Ms Merrigan. (In this regard, my Office noted that the original entry on this form in relation to the time of the fall had been tipexed out. However, this amendment was not initialled, dated or timed.) She admitted that the reference in her statement to the Gardaí, made a week after the fall, that the fall happened at 1.30am, was a mistake by her. She acknowledged that she could see why the family might be concerned about the reported time of the fall.
Nurse Harwood said that she could absolutely understand the concern of the family regarding the differences in the times recorded. When asked if there was any possibility that the patient fell from his bed at 1.30am and lay there until 2.15am, Nurse Harwood said there was no possibility that this might have happened. She said that the minute the nursing staff heard the sound, they went to the patient's aid.
Bed Side bell
The nurses said that normal practice was that a call bell was tied to the patient's bed side, within the patient’s easy reach. Its purpose was to allow a patient to alert nursing staff that some assistance was needed.
Nurse Fox and Nurse Philpot said that the complainant never spoke to any of the nursing staff about the alleged absence of a bed side bell. Nurse Morgan (Day Nurse) said that if the complainant had said anything about the bell, she would have documented it. The nurses said that all the beds have call bells attached to them and these are checked at regular intervals. They said that the patient would have been advised on admission of how to use his call bell. Nurse Grant (Clinical Nurse Manager, Day Shift) and Nurse Morgan said that if there was an occasion when one of the bells was not working, it would be rectified immediately. Nurse Harwood acknowledged that bells may fail, but not that often. On this particular point she confirmed that, if the bell is faulty, a light goes on over the bed to indicate that the bell needs attention.
Pyjamas
The nurses said that the hospital does not have the facility to launder clothes and it was normal practice to place laundry in the bedside locker. They said that if clothes needed to be washed, nursing staff would place them in a special plastic bag and put the bag in the locker prior to telling the family. They said that they have plastic bags specifically designed for clothes which are seriously soiled and that these can be placed directly into a washing machine to dissolve during the wash. It was admitted that sometimes if staff are busy, they may not get an opportunity to advise the patient's family about soiled clothes. However, it was assumed that most people would see the used pyjamas and take them home for washing.
They acknowledged that the family should have been advised that there were wet pyjamas in the locker, but stated that the deterioration in the patient’s condition was the nurses’ first priority.
Nursing staff admitted that, in order to avoid a recurrence in the future, the hospital could possibly provide written information to families explaining how the hospital handles soiled clothes.
Time on Ward after Death
Nurse Grant said that the first involvement she had with the family was when they arrived to the hospital after Mr Brown had died.
She confirmed to the family that Mr Brown had passed away at 8.10am that morning. Nurse Grant pointed out that she and another nurse followed a distressed Mrs Brown (the patient's wife) downstairs to Ward 3A, where Mrs Brown passed out. Staff stabilised her, assisted her back to the Nurses' Station and later escorted her to the Day Room for a cup of tea.
Nurse Morgan and Nurse Grant said that nursing staff would not have asked the family to leave the ward at 10 am as reported by the family, except to allow staff to lay out the body. Nurse Grant estimated that, in this case, the patient's body would have been laid out before 9am. She indicated that it takes about 5 minutes to perform this task and that the family would only have been asked to move away temporarily. She confirmed that the family had left the ward at around 11am. She said that normal practice was to allow a family to stay with the body for as long as they wanted, the family would not be rushed. Nurse Harwood also confirmed that staff would never ask relatives to leave. She pointed out that the mortuary is open 24 hours a day, so there is no rush to ask families to leave.
Nurse Morgan confirmed that the patient's body remained in the bed where he died, with the curtains pulled, until he was removed to the mortuary. During this time, normal ward activity continued. She confirmed that there were 14 other patients in the ward and that, from 2.30pm onwards, there were a number of visitors. The nurses agreed that the television may have been on, but that, generally, staff try to keep noise levels to a minimum.
When questioned as to why the patient's body was not moved to the Mortuary immediately after the family left the ward, as they had been advised, Nurse Morgan said that staff try to give the family as much time as possible with their loved one. She said that usually, when the family have gone, nursing staff ring a porter and ask for the body to be moved. She said that usually it does not take long. Nurse Harwood said that she found it very hard to believe the complainant's claim that her father was left on the ward for almost 6 hours after he had passed away.
Nurse Grant said that the body cannot be moved to the mortuary until the death has been certified by a doctor. Dr Finnegan certified the death at 12.08pm. At this stage, staff would have been on lunch so the staff complement on the ward would have been minimal. Nurse Grant indicated that there would have been two staff on the ward at this time and they would not have been in a position to move the body to the Mortuary, as the ward cannot be left with only one staff member. Nurse Grant added that there may have been a further delay waiting for a porter. She said that, as far as she can recall, the patient's remains were removed to the Mortuary in or around 2pm.
Visit from Tea Lady
Nurse Morgan was not aware of the visit from the Tea Lady and had no recollection of same. However, she confirmed that an incident like this could happen. This is because breakfast is usually being served when staff are doing their morning rounds. However, she said that if curtains are pulled around a bed, it usually signifies that someone has passed away.
She said that there were no protocols in place at the time to ensure that all staff members on the ward were alerted to the fact that a patient has passed away. However, she said that, as a courtesy, staff let people know of a death. She pointed out that a similar situation could be avoided in the future if staff informed the Catering Department that there is a death on the ward.
Nurse Harwood said that she found it hard to believe that such an incident happened. She said that it is most unusual. She explained that, once the curtains are pulled, the catering staff would not open them. Nurse Harwood made the point that catering staff usually check with nurses to clarify if there has been a death on the ward. However, she admitted that there is no notice on the ward, or on a bed, to indicate that a patient has passed away. In addition, she confirmed that there are no guidelines or rules in relation to this issue.
Procedures for moving the body to the Mortuary
Nurse Grant indicated that the procedure for moving a body to the Mortuary is that, when staff and the family are ready, a porter is called. A nurse accompanies the porter to the Mortuary to enter the details to the Mortuary Register. She said that there might not have been any contact with the porters until after 1.10pm. She also pointed out that there is a reduced number of porters on duty at weekends and, accordingly, delays could happen.
Records
Nurse Grant confirmed that there is no record of when the patient's body was removed from the ward, nor were there any procedures in place to record the removal of a patient's remains from the ward.
Post mortem
Nurse Grant said that Dr Red (Consultant Physician) was of the view that Mr Brown was to be managed palliatively after his fall. She said that, once a patient is managed in this way, there usually isn't a post mortem. Nurse Grant was present when Dr Red spoke with the family and explained Mr Brown's condition. She confirmed that the issue of a post mortem never arose.
2.4.2 - Interview with Dr Red, Consultant Physician
CT scan
Dr Red did not share the complainant's view that there was a delay in performing a CT scan on the patient. He explained that the reason the CT scan was done on the day following his admission was that the medical staff felt that a scan was reasonably urgent. However, they did not think that it was vital that the scan be done immediately on presentation, on the previous evening.
Skull X-ray
Dr Red said that he and his team reviewed the patient on the morning after his fall. He explained that the reason a skull X-ray was not performed that morning was that Mr Brown was unconscious and would have needed to be put on a ventilator to be moved down to the X-ray department. Accordingly, given the patient's condition, he made the decision that the patient was not a fit candidate for a skull X-ray at that point in time.
My Office enquired what Dr Red, or his team, might have learned from a skull X-ray at that time. He explained that an X-ray is only useful to let one document whether there is a fracture or otherwise. He pointed out that one cannot treat a fractured skull. He stated that a skull X-ray would have made no difference to the medical treatment of the patient.
He said that it would have been the wrong thing to do, given the patient's condition.
Advice after death
Dr Red said there was no question of surgery at any time for Mr Brown. When the family asked about the possibility of surgery, he stressed that this was not a realistic option for the patient, given his condition.
Post mortem
Dr Red confirmed there should have been a post mortem in this case. He explained that, where a death follows any accident in a hospital, a post mortem should be done. He acknowledged that this was clearly a case for a Coroner's post mortem and, given the circumstances of the case, the Coroner should have been informed immediately after the death.
My Office enquired whether the question of a post mortem arose at any Hospital conference where patient deaths might have been discussed, or at any time after the patient died. He explained that, on the Wednesday after the patient's death, the doctors would have reviewed the case, but he admitted there is no record of that review.
Dr Red explained that the patient died on a Saturday, but that he was not on duty at the weekend. He pointed out that the patient was buried on the following Monday, at which time it was too late to advise the family about a post mortem. He took the view that a post mortem should have been done, however, by the time the hospital was made aware of the family's concerns, it was too late.
My Office asked Dr Red, given the family's concerns, if there is anything that could be done, at this late stage, to reassure the family that their father died of a Cerebellar Haemorrhage, as is recorded on the Medical Certification of Death and that the fall had no adverse effect on his expected life span. In response, Dr Red admitted that he was not 100% sure that the death was related to the fall. He said that, if the family had raised their concerns earlier, he would have addressed them at that time.
My Office asked Dr Red if he was faced with a similar situation in the future whether he would pursue the issue of a post mortem with the family and his colleagues. In reply, he confirmed that all interns are given instructions about Coroner's cases and they are advised of the situations in which they should advise the Coroner of a death in a hospital.
Delay in notifying the Coroner of the patient's death
Dr Red reported that normally the medical staff would inform the Coroner as soon as they can. In this particular case, Dr Red said their failure to do so was a complete oversight. Dr Red advised the Coroner of the patient's death, by letter, 16 days after the patient had died. In this letter to the Coroner, he stated, "On retrospection we certainly should have informed you at the time and I am informing you now as there is some mention from the family about possible exhumation."
Medical Certificate of the Cause of Death
When asked why Dr Finnegan, Intern, did not sign the Medical Certificate of the Cause of Death, Dr Red confirmed that Interns do not sign this form. He said that it is always left to the patient's medical team to complete it.
He said that the delay of 2 weeks in completing the form was a normal delay.
My Office drew Dr Red's attention to the fact that the section on the form "Other Significant Conditions" had been left blank. Given the patient had suffered a bad fall from his hospital bed; my Office asked whether Dr Red thought that this history should have been recorded on the form. In reply, Dr Red confirmed that the doctor who completed the form, Dr Murnane, should have put "fall" in this section of the form. He did not know why it had been excluded and explained that there was no protocol involved.
2.4.3 - Interview with Dr Greene, Specialist Registrar on-call
Dr Greene said that his involvement with the family was at around 7am on the morning of their father's fall, when Mr Brown was poorly and the family was quite upset. He said that the family discussed with him their wish to keep Mr Brown comfortable. Accordingly, Dr Greene's main aim was to stabilise the patient and hand him over to the medical team at 8am. He did not discuss any procedures with the family. Dr Greene told the medical team that Mr Brown was rapidly deteriorating. He had no involvement with the patient after that time.
Dr Greene said that the fall was possibly due to the extension of Mr Brown’s stroke (a further haemorrhage), which was the primary issue. He told my Office that the family understood that their father was unwell at that stage and they said nothing about management issues. He maintained that the family did not question any of the medical decisions made about Mr Brown at that point in time.
2.4.4 - Interview with Mr Glynn, Senior Anatomical Pathology Technician
Mr Glynn explained that the purpose of the Mortuary Register, which was retained in the Pathology Department, was to record all the bodies that pass through the Mortuary. He clarified that nurses who accompany remains to the Mortuary must enter all the patient's details in it. In November 2005, these details comprised of:- the deceased person’s name, address, age and date of death, the ward on which the patient died, the next-of-kin, a contact phone number for next-of-kin and clarification as to whether a post mortem was to be conducted or not. The last entry required a Yes or No for whether a post mortem was required. Mr Glynn clarified that, while the nurse completed the entry in the Register, the actual decision to undertake a post mortem was a clinical decision of the doctor. In the case where a post mortem was required, Mr Glynn explained that the patient's doctor had to ring the Mortuary and tell them that a post mortem was required.
My Office drew Mr Glynn's attention to the fact that, in the column for "post mortem Yes / No", the first entry for Mr Brown, which indicated a "yes”, was pencilled / scratched out and changed to "no". Mr Glynn did not know who made the unsigned change or the reason for it.
My Office enquired whether, there was any record to show the time that Mr Brown’s remains were received in the Mortuary, the time the remains were dispatched from the Mortuary, who took possession of the remains or where the remains were taken to. In response, Mr Glynn confirmed that such records were not maintained at the time; however, he clarified that these details are being recorded in the new system introduced since this complaint was received.
2.4.5 - Interview with Ms Merrigan, Hospital Business Manager
Mortuary Register - Specific Entry
In relation to the failure to initial the change to the original entry in the Mortuary Register, Ms Merrigan indicated that, sometimes nurses do not adhere to the best practice standard of initialling and dating any changed entries. Her view was that there was never any intention to conduct a post mortem on the patient and that there was no significance to the changed entry in the Mortuary Register. A post mortem had not been requested because Dr Greene had earlier agreed with the family that the patient was to be kept comfortable. She said that it was clear that the patient was dying and that this was possibly a result of his presenting condition. She said that there might have been a breakdown in communication between members of the family.
In relation to the changed entry for the "time of incident" on the Incident Report Form, Ms Merrigan acknowledged this and said that she did not make the change to the form. She agreed that the revised entry should have been initialled by the person who changed it.
My Office questioned why the Incident Report Form received by the Risk Management Department two days before his death did not prompt a follow up on the patient when he died shortly thereafter. In response, she said that the hospital did not link the patient's death with the fall and indeed they only became aware that there were issues with this case when Dr Red rang her to let her know that he had had a visit from the patient's daughter, about 3 weeks after Mr Brown’s death.
2.4.6 - Interview with Dr Finnegan, Medical Intern on-call
Mr Brown's Condition
Dr Finnegan was the Medical Intern on call on the night of the patient's fall, from 12 midnight to 4am. He pointed out that Mr Brown was a patient of Dr. Red and he was not familiar with him. Therefore, before he tended to his condition, he had to read the patient's medical and nursing notes. He said that when he found the patient, he had a big gash on his head, a broken tooth, he was drowsy and his eyes and pupils were okay. He said that the patient's GCS was 13 (out of 15). Therefore he concluded that the patient was not having another stroke at that time. However, Dr Finnegan noted that the patient's blood pressure was very high. As he was a junior doctor at the time, he consulted with Dr Greene, Registrar on Call and the surgical doctor. Dr Finnegan was advised to put a bandage on the patient's head; he was advised that the surgical doctor was not available to suture it at that point in time.
Time of fall and notifying the family
Dr Finnegan's notes in the medical chart record that the patient fell at 2.20am. He made the point that, in the situation which presented itself, the notes are the last thing one has to attend to. He explained that one needs to talk to nurses, review the patient's notes, assess the situation and treat the patient and that therefore the times recorded may not be fully accurate.
As the patient's GCS was 13 when he came upon him, his view was that the patient was relatively stable and he did not feel that there was any significant elapsed time between the fall, the doctor being called and the doctor attending to the patient. My Office asked why the family was not notified immediately about the accident. In response, Dr Finnegan pointed out that this is not the responsibility of an Intern. His primary function was to stabilise the patient and to talk to a senior doctor about his condition. In any event, Dr Finnegan said that, given the patient had a GCS of 13 (out of 15), it would not normally be necessary to call the family, particularly at that time of the night.
Time on Ward after Death
Dr Finnegan pronounced the patient deceased at 12.08pm. He could not explain the elapsed time of almost 4 hours, from the time the nursing notes record that the patient died, 8.10am. Dr Finnegan said that he could not recall if the family was on the ward when he pronounced the patient dead and he did not know how long the patient's remains stayed on the ward after this.
The question of a post mortem and the Mortuary Register
Dr Finnegan said that he was aware of the hospital's policy in relation to post mortems and of the statutory requirement to report deaths which are sudden, unexpected or due to unnatural causes to the Coroner. He reported that the question of a post mortem was not considered by him as the fall had happened 48 hours earlier and Dr Red's team had seen the patient after his fall. Dr Finnegan also clarified that he had no decision making role in relation to this patient or in relation to the question of a post mortem. He clarified that he was not working with Dr Red's team and Mr Brown was not one of his patients.
Dr Finnegan confirmed that his job was only to certify the patient dead. He said that he had no role with regard to deciding on a post mortem, or with regard to the Mortuary Register.
The signing of the Medical Certificate
Dr Finnegan explained that he did not fill out or sign this form for two reasons; he only had temporary registration on the Medical Register and therefore he was not allowed to sign such a document; and he was not a member of Dr Red's team to which Mr Brown was assigned. His only role was to stabilise the patient after his fall.
.4.7 - Interview with Dr Murnane, Registrar to Dr Red, Consultant Physician
Dr Murnane commenced a one year term in Limerick Regional Hospital in July 2005 as Dr Red's Registrar. He saw Mr Brown on admission and on a number of occasions during his stay in the hospital. Dr Murnane was not on duty when the patient fell, nor when Mr Brown passed away. He had attended to him in the period after his fall and prior to his death.
Dr Murnane explained that Mr Brown was admitted with intracranial bleeding. He said that, at that stage, Mr Brown was at a high risk of dying. He had a bleed in his brain which was seen on the CT scan in Cork University Hospital. As a result, it was decided that the patient was not for surgery. Dr Murnane said that the bleed was significant and the medical staff were concerned that the patient might die.
Dr Murnane said that, following Mr Brown's fall, Dr Red knew that the patient had deteriorated. Dr Red considered, from a medical point of view, that there was nothing to be gained from undertaking another X-ray. When asked whether it would it have been good practice to have scanned the patient after his fall, Dr Murnane clarified that there was a long discussion about this, overnight. It was later discussed with Dr Red in the morning and it was decided not to perform a skull X-ray or to do a further scan.
Dr Murnane said that the question of a post mortem did not arise in any discussions with members of the family. He said the family did not raise any concerns. The medical staff thought that Mr Brown died of his presenting condition and that his fall was not related to his death. They believed that his death was related to an extension of his earlier bleed. Dr Murnane said that if he was faced with a similar situation in the future, he would like to think that the consultant would be told about the patient's death on the Monday morning, following the week-end, and possibly the issue of a post mortem considered there and then.
Dr Murnane could not recall whether Mr Brown's case was discussed at the weekly Case Conference, however, he was clear that the issue of a post mortem was not raised. In relation to the entries in the Mortuary Register, he said that no one would have advised staff on the ward that Mr Brown was for a post mortem.
Dr Murnane said that Mr Brown was not classified as a Coroner's case by Dr Red at the time. He explained that the family approached Dr Red later and this approach, combined with his fall, prompted Dr Red to ring the Coroner (Appendix 4) about the case.
He explained that the hospital has a good record of notifying the Coroner of deaths. He said that a death involving trauma or anything that was unusual would normally have been alerted to the Coroner. Dr Murnane's view was that the patient lost consciousness and fell from his bed following a second bleed to his brain.
Dr Murnane considered that the length of time taken to sign the Medical Certificate was normal. He explained that the patient's chart is not sent to a doctor for some time as it has to go to the Mortuary, to the registry and to the consultant before the Registrar receives it. When asked to explain why the section of the form "Other Significant Conditions" had been left blank, Dr Murnane said that, at this particular time, and in his view, the fall was not considered to have been a contributory factor to the patient's death. He also clarified that he did not discuss the case with Dr Red before completing the form.
Dr Murnane said that, from a medical point of view, the doctors should have discussed, in advance, the question of a possible post mortem for Mr Brown. He also mentioned that the Risk Management Department was aware of the fall and that it should possibly have acted on the case when Mr Brown died, and should possibly have contacted Dr Red to get his views on the need for a post mortem.
2.4.8 - Interview with Ms. Stokes, Nurse Care Assistant
(When my Office discovered that the Mortuary Register had initially indicated that a post mortem was required, we asked the Hospital to identify who had accompanied the remains to the mortuary and made the entry in the Register. It took the Hospital eight months to do so. By this time, my investigation was at a very advanced stage, with all other interviews completed. My Office immediately made contact with the person named, Ms Stokes, Health Care Assistant, but she was leaving for Australia the next day and she could not meet with my staff. A phone-call proved unsatisfactory and so instead, a number of written questions were sent to her and she was asked to respond, to the best of her ability.)
While it is not recorded in the ward or mortuary records, Ms Stokes accepted that she accompanied Mr Brown's remains to the Mortuary. She could not recall how long the remains were left on the ward or why there was a delay removing them. Ms Stokes confirmed that she made the initial entry in the Mortuary Register. She said “with the situation in hand I automatically wrote yes, then I obviously rang the ward to confirm and was told no”.
When my Office asked Ms Stokes the reason why she initially placed a "yes" in the column for "post mortem", she stated that she "didn't know, she just automatically did it."
She said that she then rang the ward to confirm whether the remains were for a post mortem and was told that they were not. She then changed her earlier entry to a "No", signifying that a post mortem had not been ordered. She could not remember to whom she spoke.
(Given the very late stage in the investigation when my Office was enabled to make contact with Ms Stokes, the fact that it was then almost 4 years since Mr Brown’s death and the fact that at the time of issuing the draft report, Ms Stokes was still in Australia, my Office decided that it was not practical to pursue Ms Stokes further regarding what she meant by her comment “the situation in hand”, leading her to write “Yes” into the Mortuary log.)
3.1 - Delay in performing CT Scan
The complainant in this case felt that her father should have had a CT scan shortly after he was admitted to hospital. From my examination of the patient's medical file, it is clear that Mr Brown was admitted to the A&E Department in Limerick Regional Hospital at 9.26pm on a Friday. At 0.40 hrs on Saturday it was decided to do a CT scan; this was within 4 hours of his admission. The scan was done at 1.20pm on Saturday, 16 hours after the patient's admission. Dr Red, Consultant Physician, was satisfied that this timescale was reasonable given Mr Brown's presenting condition.
The complainant feels that her father was disadvantaged by not having his CT scan on the Friday. Dr Red is of the view that it was appropriate for the CT scan to be performed on Saturday. His view was that, while a CT scan was necessary, it was not an immediate priority, as his clinical view was that a CT scan was not going to alter the medical management of the patient.
As the decision to perform a CT scan on the Saturday, rather than on the Friday was a clinical decision of the medical staff, this aspect of the complaint is outside my remit.
3.2 - Observation of the patient's fall
The complaint is that the patient's fall, or the moments leading up to it, was not observed by any of the five nursing staff on duty and there is a concern by the family that Mr Brown may have been unattended to. The HSE clarified at the early stages of this investigation that Mr Brown had been moved, two days after admission, from the Intensive Care Unit to a general medical ward where less supervision was available. From my Office's interviews with staff members on duty on the night in question, it is clear that the patient's fall was not observed. A permanent staff presence is not required in each general ward room at night time. Mr Brown had been moved to a bed that could be more easily observed by nursing staff at the Nurses’ Station. Two nurses were present at the Nursing Station and were writing up patients' nursing notes. The only light source in the ward was provided by the floor strip lighting. The two nurses did not see or hear Mr Brown’s initial attempt to get out of bed. When they heard the sound of furniture moving, they say that they looked up and ran to his assistance. It is clear that the fall was not actually observed, however, once the staff heard a movement in the ward, they went to the patient's assistance immediately.
3.3 - Falls Assessment
While it may be reasonable that the patient’s fall was not observed, I believe further attention should be given to why Mr Brown fell in the first instance.
Mr Brown was admitted to hospital with a cerebellar stroke which affected his balance and resulted in him requiring assistance to walk. Mr Brown was found on the floor beside his bed. It seems that he did not simply roll out of the bed while asleep. This is based on the fact that some nurses reported that the bed-side rails were up, but also, there is consensus that he was found at the end of the bed, signalling that he had moved from a regular position in the bed, to the bottom of the bed. It is reasonable to assume that Mr Brown attempted to stand up, but fell. He may have fallen because of his pre-existing balance problems, or, because of a worsening of them, due to an extension of his stroke. Regardless of which was the case, the evidence available to me suggests that Mr Brown was, from admission to hospital, at risk of falling in attempting to get out of bed and in attempting to walk.
Falls are, unfortunately, a common occurrence in hospital, causing distress, suffering and indeed mortality. Therefore, the evidence suggests that major efforts should be made in all hospitals to minimise their occurrence.
The Mid-Western Regional Hospital’s Falls Policy states that a patient's risk of falling should be assessed and appropriate measures put in place to minimise any identified risk. Any perceived risk should be documented in red ink in the patient's notes. The policy covers particular risks, such as where patients are unsafe mobilising to the toilet, and states that these patients should be assessed and the need for a commode or urinal considered.
In Mr Brown's case, although a falls policy existed in the hospital, it is not documented whether a comprehensive falls risk assessment was undertaken. It is clear that some measures were taken to reduce his risk of falling, but it appears that these were not as comprehensive as the policy dictates. A falls risk assessment might have considered, among other issues, whether Mr Brown was vulnerable to a fall, whether it was appropriate to use bed side rails on his bed, whether he needed to be accompanied to the bathroom, whether he would benefit from a urinal or commode beside his bed, and whether he was capable of using the call bell to seek assistance (at the same time ensuring that it was accessible and working).
In relation to the bed side rails, two of the nurses advised me that the patient's bed side rail was down immediately after the fall, while another advised me that the rail was up. There was no documented evidence to support either claim. This is a significant issue as there has been a substantial number of adverse incidents recorded internationally involving side rails that have led to serious injury, and hence they should only be used selectively with specific patient groups. I have seen no documentary evidence to suggest that such consideration or risk assessment was carried out in the case of Mr Brown, and I have received conflicting reports about whether they were in use on this occasion. This is very unsatisfactory from my point of view.
3.4 - Waiting four hours to advise the family of the patient's fall
The complaint was that the patient suffered a serious fall in a medical ward, yet there was a delay of four hours in advising them of this. Having interviewed the nurses on duty on the night in question, and from an examination of the nursing notes and the Neurological Observation Charts, it is clear that the patient was being observed very closely by staff following his fall. It took about 20 minutes to stop the bleeding from the patient's head, but during this time the patient was closely attended to and conscious although confused. However, his condition deteriorated as the night went on and his Glasgow Coma Scale went from 13 out of 15, to 8 out of 15 over the following four hours or so.
When a patient's condition is stable, it is not always necessary or appropriate to contact a family in the middle of the night, even following a fall. My view is that each case has to be determined on its own merits, having regard to the observed condition of the patient. One also has to consider whether a family might welcome a call from the hospital in the middle of the night, when the hospital was of the view that the patient's condition was, at that time, stable. Some consideration had also to be given to the other 14 patients asleep on the ward at the time.
In this particular case, the patient was being observed, and his condition monitored and recorded, every 15 minutes. It is clear that once his condition deteriorated, the Medical Registrar was consulted and a decision was made at 5.30am, to contact the family. Having regard to the situation which presented on the night in question, I am not convinced that there was an overriding or compelling case for the medical and nursing staff to contact the patient's family sooner than they did.
3.5 - Time of the fall
The complaint was that there were three different recordings of the time of the fall, ranging from 1.30am to 2.15am. (In fact, during the course of my examination of the complaint, I came across a fourth record of the time of the fall.) It is clear that there is inconsistency in the recording of the actual time of the patient's fall. This is significant for the family who are anxious to know exactly what happened and how quickly their father was attended to. The HSE said that the time recorded is approximate, because attending to the patient's immediate needs is staffs first priority. It explained that every effort is made to ensure that the recording of details is as close as possible to the time of the event.
It is, however, somewhat unsatisfactory that four different times for the fall, spanning a period of 50 minutes, were recorded. This does not reassure the family that their loved one was cared for immediately and adequately after falling. However, despite the lack of clarity on the time of the fall, based on the evidence before me, I am satisfied that staff did hear the patient fall and that once this happened, they attended to his medical needs immediately. This incident highlights the importance of making and keeping accurate and timely records.
3.6 - Skull X-ray
The complaint was that the medical notes suggested that a skull X-ray was to be performed on the patient following his fall; however, this X-ray was not conducted. In his interview with my investigative staff, Dr Red, Consultant Physician, explained why Mr Brown was not a suitable candidate for a skull X-ray when his team reviewed him following his fall. As this was a clinical decision taken by the relevant medical staff, this aspect of the complaint is not within my remit. However, from an examination of the records, I am satisfied that the issue of a skull X-ray was noted in the medical notes at the time, was reviewed by the senior personnel the following morning and a clinical decision was made in relation to the issue, having regard to the patient's presenting condition.
3.7 - Bed Side Bell
The complaint was that there was no call bell beside the patient's bed before he fell from his bed. The family contend that they had noted this on the day before the fall and when they arrived at the ward after the fall, but they did not bring it to the attention of hospital staff at the time.
Call bells provide disabled, unwell and vulnerable patients with a critical communication link with hospital staff. It is essential that all patients who are capable of using them, have easy access to a fully functioning call bell.
When I raised this issue with the HSE, I was told that the Hospital Business Manager was "advised by the Ward Manager that all of the beds have bells." However, when I sought a copy of the Ward Manager's original report, her report actually stated that “Every bed on the ward should have a call bell over the bed". These are two very different responses, with the HSE's formal reply to my Office claiming more than was actually advised by the Ward Manager. The Ward Manager's response seems appropriate; all beds should have a bell. However, her response did not address the substance of the complaint, namely that there was no bell over the bed in this particular instance.
I was told during interviews with nursing staff, that there is a register containing the maintenance history of all call bells on the ward. This register records if there were problems with any installations, including call bells. However, when I wrote to the hospital and asked for a copy of the maintenance history register for the call bells in the Ward for the period in question, I was told there was no copy for that period. Subsequently, my staff pursued this issue at interview with Ms Merrigan, Business Manager and they were told that the register may have been discarded, but she undertook to have the nursing staff conduct a further search. My staff later wrote to the Business Manager and in response were told that, while records exist for the periods September, October and December 2005, - copies of which I received - there was no record available for November 2005. I was also told that there was no written guideline in relation to the practice of checking essential utilities, including the call bells and oxygen.
It is not acceptable to me, as Ombudsman, that reports from staff members in relation to specific issues which I raise, are altered by senior staff members before the formal response is received in my Office. My role is to examine complaints and to determine, on the balance of probability, whether there are issues of maladministration. Therefore, when I ask a specific question, I expect the public body to respond in good faith and to represent, as accurately as possible, the actual information which it has in its possession. I am not convinced that this is what happened in this instance in relation to the call bells. The family contends that there was no bell available to Mr Brown the day before he fell or on the morning after his fall. The fact that the maintenance history register for the particular call bells for the periods pre and post the incident are available, but the necessary register for the period under examination is not available, heightens my concerns in this regard. Mr Brown was a vulnerable patient for whom a call bell was essential.
3.8 - Mortuary Register
The Hospital's Mortuary Register recorded only limited details in respect of each death in the Hospital. My investigation found that an important entry in the Mortuary record was changed, and given the controversy that existed about the absence of a post mortem, this record and the changes made to it, were the focus of my attention. However, following a request from my Office, it took the Hospital eight months to identify the person who accompanied the remains to the Mortuary and completed the register entry. This person was then unavailable for interview and although my Office sought a written account of what had happened, the information received was less than an interview might have facilitated. Given the absence of a signature on the register, the delay in identifying the person who made the entry, the changes made and the paucity generally of information in the register, the register proved of little use to me.
A basic requirement in any medical record management system is that adequate information is recorded, that all records are signed and that no content is erased or destroyed, even if incorrect. If a correction is to be made, good practice is that the original entry should remain visible. These basic qualities are required to facilitate good communication, transparency and the monitoring of standards and or quality.
3.9 - Failure to carry out a post mortem
A post mortem examination is a medical examination of a dead body to determine the exact cause of death.
The complaint is that there was a failure to carry out a post mortem in line with hospital policy following the death of the patient; that there was a failure to advise the family of its rights to have a post mortem conducted, and that there was a failure to discuss the patient's death at a subsequent conference with other medical staff.
I should explain that there are two types of post mortems, a hospital post mortem and a Coroner's post mortem. The hospital's procedures for a hospital post mortem provide that permission must be obtained from the patient's nearest relative or some other relative who is willing to take responsibility for granting permission to do a post mortem. The permission must be obtained by a doctor, preferably a Registrar of a Senior House Doctor (SHO) and recorded and signed in the patient's chart.
In relation to Coroner's post mortems, the hospital's procedure stipulates that the following deaths should all be Coroner's cases: Violence - direct/ Indirect, Unnatural, Sudden or unknown cases, Suspicious circumstances, Misadventure, Negligence, Misconduct, Malpractice, Anaesthetic and Operations.
The procedures also provide that any cause other than natural illness or disease for which the patient has been seen and treated by a medical practitioner within one month of death should be referred to the Coroner. In addition, the hospital procedures provide that if a patient dies within twenty four hours of admission to the hospital, the need for a Coroner’s investigation may be discussed with the Coroner. The final decision on cases to be notified to the Coroner rests with the Consultant.
It is clarified that the request for a post mortem should be submitted to the Pathologist on Post mortem Duty by 11.00 hours by a member of the medical team (weekends and bank holidays included) and it is the responsibility of the medical team on duty at the time of death to arrange the post mortem.
I am very conscious of my role as Ombudsman, versus the role of the Coroner. The Coroner is an independent office holder with legal responsibility for investigating sudden, unexplained and unnatural deaths in his district. My job is to examine complaints from members of the public who feel they have been adversely affected by the administrative actions of certain public bodies. It is clear that on occasion, it is in the best interest of the public, for both the Coroner and me to examine circumstances around a death, admittedly with each of us having a different focus. In examining the post mortem aspect of this complaint, I was clear that my examination would concentrate on the alleged maladministration leading up to, and associated with, the decision or lack of decision to perform a post mortem or to notify the Coroner of the need for one.
In its initial response to my Office, the HSE said that a post mortem was not considered at the time of the patient's death, nor was it discussed with the family. The HSE said that this was an oversight on the part of the medical team. It also made the point that the agreement of the family to keep the patient comfortable after his fall may have influenced the decision not to conduct a post mortem.
In the course of my Investigation, the Mortuary Register was sought and an initial entry confirming that a post mortem was required was noted by my staff. My Office investigated this further, but as explained previously, several factors resulted in my being unable to satisfy myself fully of whether this was a simple error, or something more. In the absence of evidence to support the change to the Mortuary Register being anything other than a simple error, my investigation then moved its focus to other evidence of maladministration and adverse affect.
My understanding is that post mortems are regularly conducted following the death of a patient in a hospital, in certain circumstances. In this particular case, given the patient's history in the hospital (that his condition was improving, but he then suffered a very bad fall, he rapidly deteriorated and died 52 hours after his fall), it was particularly important that the question of a post mortem should have been considered and raised with the Coroner and the family.
As Ombudsman, I believe it is reasonable to expect that when a person dies in hospital, the question of a post mortem is considered by the patient’s medical team and an informed decision made. If a patient is dying and the patient’s medical team are not going to be on duty for a time, as happened in this case, then I would expect that some direction be given in the medical chart or to nursing staff who will be on duty, about the issue of a post mortem. However, in this case, it is clear from the interview with Dr Murnane, Dr Red's Registrar, that the question of a post mortem for Mr Brown was not discussed by the team while they were on duty on the Thursday and Friday after the fall, when Mr Brown was dying. No member of the team was available on the Saturday morning when Mr Brown died, or for the remainder of the weekend, and no procedure existed to allow contact with them off-duty. They had left no instruction in advance to assist on-call staff with the matter and Dr Finnegan, the Intern on-call, did not feel that it was his duty to determine if a post mortem was required.
It seems that it was Monday morning, two days after Mr Brown’s death, before his medical team were informed of his death, by which stage the funeral was taking place and it was too late to arrange for a post mortem. Finally, whilst Dr Red recalls that Mr Brown’s death was discussed informally at a case conference the week after he died, Dr Murnane says that a post mortem was not discussed and the discussion did not prompt a phone-call to the Coroner.
My view is that Mr Brown's death and the question of a possible post mortem should have been discussed immediately with senior medical personnel. As the patient’s condition had started to deteriorate significantly at the time of an adverse incident and as the patient was deemed to be dying on the Friday that his medical team were going off duty for the weekend, a post mortem should have been discussed and some direction left to guide decision making, should the patient die when his team were off-duty. In addition, the fact that a patient died within two days of the completion of an Incident Report to the Hospital's Risk Management Department, citing a significant adverse event, suggests that the hospital's systems should have been alert to the need to consider a post mortem. I am concerned that there appears to be no linking of the reporting of a significant adverse event, with the follow up care of the patient.
The fact that the Hospital, the Consultant, Dr Red and the Risk Management Department did not implement their own policy on post mortems and failed to notify the Coroner for some time after the funeral, has adversely affected the complainant and her family. The open verdict of the Inquest has somewhat reinforced the family’s serious doubts about the actual and contributory causes of their father's death. A post mortem at the time of death would have reassured them that they had all the relevant information about their father's death.
Normally, in the course of my investigations, when I see that a hospital and medical team have admitted to some poor administration and apologised for it, I let the matter rest and I do not feature it in my report. However, in this instance, I am not convinced that appropriate measures have been taken to prevent the same error occurring again. The Coroner has fulfilled his role in this case and the inquest was held on 26 April 2006.
The purpose of an inquest is to establish the facts surrounding the death, to place those facts on the public record and to make findings on the identification of the deceased, the date and place of death, and the cause of death. According to general literature from the Coroner, the open verdict returned can be appropriate in circumstances where there is insufficient evidence for a verdict of accident. An open verdict means that the evidence does not fully or further disclose the means by which the cause of death arose.
I am interested in the maladministration which led to the events in question and I am concerned that systemic issues which might affect other people and which require attention in order to prevent the same error recurring have not been addressed.
I believe that there were two main contributory factors to the failure of the hospital to complete a post mortem. Firstly, the significance of the fall may have been under-estimated or under-valued by nursing, medical and risk management staff. Dr Finnegan who treated Mr Brown immediately after the fall told my investigation that Mr Brown was conscious, with a GCS of 13 and no evidence of a further stroke. However, Dr Murnane and Dr Greene have expressed an opinion that Mr Brown suffered an extension of his stroke which caused him to fall.
It is the latter opinion which seems to have influenced the oversight regarding the need for a post mortem. In any event, I believe there was a lack of joined up thinking between all staff (medical, nursing and risk management) that could have ensured that adequate consideration was given to the fall’s contribution to Mr Brown’s death, or at very least, recognised that there would be unanswered questions if a post mortem was not requested.
The second contributory factor to the failure to advise the Coroner of the need for a post mortem was, I believe, related to medical cover at the weekend, the time when Mr Brown died. As mentioned above, the hospital's procedures on post mortems provides that the final decision on cases to be notified to the Coroner rests with the patient's Consultant, but that the medical team on duty have responsibility for arranging the post mortem. No member of the medical team responsible for Mr Brown’s care was on duty that weekend and no advance instruction had been left for the on-call team with regard to the serious fall experienced. On the surface, Mr Brown had been admitted with a very serious condition for which he was receiving medical attention. A junior on-call doctor was called to certify the patient dead; he was not asked to consider a post mortem. He told my Office that he had no role in ordering a post mortem, that this was a matter for the Mr Brown’s medical team, but no member of this team was on duty, nor were they contacted by medical or nursing staff. Had they been contacted, or had the medical record and nursing notes drawn attention to the possible significance of the fall and provided information for the on-call team, a decision to contact the Coroner could have been taken then, rather than over two weeks later when prompted by the family and the Gardaí. I am aware that the Coroner asked for better education and training of junior doctors about procedure relating to post mortems, but I am not convinced that adequate attention has been given to arrangements when the patient’s medical team are off-duty.
As Ombudsman, I must examine whether hospitals and their staff have good systems in place to ensure good administration and decision making. In this case, it appears that the hospital’s communication and its policies were flawed. The Hospital and the Consultant, Dr Red, have acknowledged that a post mortem should have been completed, but I see no evidence of measures taken to prevent these unfortunate set of circumstances happening again. It is imperative that there be greater awareness and vigilance by medical, nursing and risk management staff regarding deaths which follow serious incidents, and that measures are put in place to ensure appropriate actions are taken. Clarity is needed in relation to the position at weekends and during periods of leave, regarding whose responsibility it is to request a post mortem. If it is the responsibility of an on-call team, who may be unfamiliar with the patient, then it is imperative that measures be taken to ensure that they are fully informed in making their decision. In the current case, it appears that there was confusion over whose responsibility it was to order a post mortem and, if it was the responsibility of the on-call team, they had little information available to assist them with making an informed decision.
3.10 - Treatment of the remains and family on the ward
Given the poor record keeping on the hospital ward with regard to the arrangements for the management of the remains on and from the ward, I was unable to establish for certain how long the patient's body remained on the busy ward following his death. However, it is clear to me that Mr Brown's body was probably on the ward for a minimum of 6 hours.
During this time, the normal activities of patient care were being carried out; staff were assisting patients with commodes, writing notes, doing their rounds, and dressings and caring for the other patients on the ward. There were visitors to the ward, the television was on, and the normal background noise associated with a busy hospital ward could be heard. Meanwhile, the Brown family was expected to grieve for their recently deceased father in this setting; the only privacy afforded to them was a plastic curtain around his bed, in the corner of the busy hospital ward.
This is not an appropriate setting in which to mourn the death of a loved one. It is clear that the family was not provided with the basic facilities of privacy in the moments following the death of their loved one. My view is that, where appropriate, patients and their families have a right to be catered for in facilities which afford full privacy and dignity. This was not the case in this instance.
3.11 - Visit from Tea Lady
The complaint was that, shortly after his death, a Tea Lady enquired if Mr Brown wanted breakfast. While none of the staff could recall the particular scene, I am satisfied that this incident did occur. The incident points to a lack of communication between the Ward Manager and catering staff, and to some extent, a lack of respect for the remains and the bereaved family on the ward. The family were understandably hurt by the insensitivity of the event, although not critical of the Tea Lady herself.
3.12 - Possibility of Surgery
The complaint was that, after the patient died, the family was told by Dr Red that their father could have had surgery after he presented to the hospital with his original cerebellar haemorrhage.
When my staff put this complaint to Dr Red, he was adamant that there was no question of surgery at any time for Mr Brown. He reported that, while he was asked about the possibility of surgery, he had always said that surgery was not a possibility in the circumstances of this patient.
I have considered the complainant's recollection of events. While I am not questioning the bona fides of her claim, this is one of those instances where there are two different versions of events and which, in the absence of independent evidence to support her case, it is not possible for me, as Ombudsman, to reconcile the direct conflict of evidence between the complainant's recollection of events and that of the relevant hospital Consultant.
3.13 - Delay in signing the Medical Certificate of the Cause of Death
The complaint is that there was a delay by the hospital in signing the Medical Certificate of the Cause of Death. The complainant needed a copy of her father's Death Certificate in order to register his death with the General Register Office (Appendix 6). On arrival at the hospital, just under two weeks after his death, she was advised that there was no record of her father's death on the hospital's computer system. She was advised to call to the ward, where she discovered her father's medical file.
Dr Murnane, Dr Red’s Registrar, contends that the Death Certificate, being signed within 12 days of the patient's death, was within normal accepted standards.
I can find no just reasons to suggest why the patient's medical file should have been on the medical ward almost two weeks after the patient had passed away. In addition, I do not think it is acceptable that a daughter, on visiting the hospital, should have to bring her father's medical file from a hospital ward to the hospital's Records Department to ensure that the hospital's records are updated. This task should have been performed by the relevant hospital staff, and certainly long before the complainant called to the hospital. This particular incident begs the question of how long the patient's medical file might have remained on the ward, had my complainant not enquired about it.
In saying this, I note that the hospital's computer Patient Administration System (PAS) was updated at 17.16 hrs on the day of Mr Brown's death.
3.14 - Delay in Notifying the Coroner of the patient's death
The Coroner is an independent office holder with responsibility in law for the investigation of some deaths. There is a legal responsibility on all medical doctors to report deaths that are sudden or occur unexpectedly or are due to some unnatural cause.
I note that the hospital readily admits that there was a delay in notifying the Coroner of the patient's death. As already stated in Section 3.8, I perform a very different role to the Coroner who arranged for an inquest on this case. I am concerned with other aspects of the death of Mr Brown, namely maladministration causing adverse effect to patients and families in similar circumstances to this case. Part of my role is to ensure that where maladministration occurs, relevant measures are taken to prevent it from recurring. I do not consider that in this instance, sufficient measures have been taken to prevent such delays in contacting the Coroner from happening again. I have already dealt with this in detail in section 3.8 of this report.
3.15 - Record keeping
The nursing and the medical notes in this case are generally comprehensive. They provide a clear guide to the level and extent of the nursing and medical care which the patient received during his stay in the hospital.
Notwithstanding this, this complaint has proven to be a very difficult case to examine, not just because of the subject matter and the family's grief, but because of the paucity of good record keeping in some areas of the hospital, the lack of clarity about certain changes to key records, and the failure of the hospital to identify, in a timely fashion, some staff members who were responsible for entering, and changing key records. There was also an absence of records to clarify the significance of the patient's fall and to help inform on-call staff of the need to consider the implications of the fall when deciding on the need for a post mortem.
3.16 - The family’s wishes with regard to an exhumation and post mortem
In the course of my investigation of this case I was at all times conscious of the distress suffered by the family with regard to Mr Brown's untimely death. I was also conscious of a number of actions or inactions by the HSE, whilst Mr Brown was under their care and at the time of his death, and of the family’s deep concern that the fall suffered by their father led to his death.
The family regretted deeply that no post mortem was completed to identify whether the cause of death was related to his stroke, or whether indeed to the bad fall he suffered whilst in hospital. In complaining to my Office the family told me that they wanted a post mortem performed, even at this very late stage when it would require an exhumation of the body.
As stated already, my role is not to determine the cause of death and therefore, I have no powers to pursue this aspect of the family’s complaint. Section 47(1) of the Coroners Act, 1962 provides that the Coroner may request the Minister for Justice to order an exhumation of a body in certain circumstances. Following an Inquest into the death, in April 2006, the Coroner did not request the Minister for Justice to do this. However, in his report on the case, the Coroner suggested to Dr Red that the junior staff be made aware of the requirements to notify the Coroner of a death in certain circumstances.
Introduction
Mr Brown was a 61 year-old man who died following a stroke and a bad fall. He left behind him a grieving and committed wife and family. My investigation has sought to establish what happened in his final days and whether there was any maladministration involved in relation to his care and in relation to the treatment of his family. My examination has shown that much of the care afforded to Mr Brown was of a high standard, but it also uncovered unacceptable administrative failings which should be acknowledged, apologised for, and steps taken to prevent them from happening again.
4.1 - Post mortem and notification of Coroner
I believe that it is reasonable for the family to have doubts about the HSE's contention that Mr Brown’s death was caused purely by his stroke and not contributed to by the bad fall he suffered whilst in hospital. The hospital failed to carry out a post mortem in line with hospital policy or to advise the family in this regard. The hospital failed to advise the Coroner of the patient's death in a timely fashion. I find that these actions have adversely affected the Brown family and the actions were, or may have been, the result of carelessness having regard to Section 4(2)(b)(iii) of the Ombudsman Act, 1980. Although the HSE has admitted to many of these failures, I am not satisfied that appropriate measures have been taken to prevent such failures from happening again.
4.2 - Treatment of the remains and family on the ward
Due to the absence of official records it was not possible for me to ascertain with complete accuracy how long the patient's remains were left on a busy ward, after the family left the hospital. However, on the balance of probability, it appears that the patient's remains could have been on the ward for approximately six hours, several of which were after the family had left. I find that the absence of the relevant records in this instance is an undesirable administrative practice, having regard to Section 4(2)(b)(vi) of the Ombudsman Act, 1980.
Mr Browne and his family were not afforded the basic standard of dignity or privacy in the final moments of his life, or in the hours the remains were left on the ward subsequently. While it may not have been possible to obtain a side room, there was a failure to alter activities on the ward or notify catering staff and visitors of the death of someone on the ward and the fact that the remains were still present. I find that these failures were the result of negligence or carelessness, having regard to Section 4(2)(b)(iii) of the Ombudsman Act, 1980.
4.3 - The patient’s fall
I am not satisfied that the hospital implemented its own policy with regard to the management of falls. Mr Brown was clearly unsteady on his feet and needed assistance to mobilise to the toilet.
i) Bed Side Bell
The original report to my Office, in respect of the call bell, tried to convey an impression to me, which was inconsistent with the facts as observed and reported to the HSE by nursing staff on the ward. I find that this is an undesirable administrative practice, having regard to Section 4(2)(b)(vi) of the Ombudsman Act, 1980.
The Maintenance History Record, in respect of bed side call bells, for November, 2005, was not available, although the records for other months were. I find that this is the result of negligence or carelessness, having regard to Section 4(2)(b)(iii) of the Ombudsman Act, 1980.
It was not possible for me to ascertain with certainty whether there was a functioning call bell on the patient's bed before he fell, and the accounts from the family and nursing staff differed. There is a significant shadow of doubt as to whether Mr Brown had access to a call bell to seek assistance. I find that this is unacceptable, given the critical role of this basic piece of equipment for this vulnerable man.
ii) Observation of the patient's fall
The patient's fall, or the moments leading up to it, was not witnessed by any of the five nursing staff on duty, only two of which were on the ward at the time of the fall. I am satisfied, however, that the relevant staff were alerted to the fall and attended to the patient immediately.
iii) Bed Side Rails
I found no documentary evidence to clarify whether the use of bed side rails had been properly considered for Mr Brown. I find that this represents undesirable administrative practice. There is also conflicting evidence as to whether bed rails were in use or not.
iv) Time of the fall
There were four different recordings of the time of the patient's fall, varying by 50 minutes, with some unauthorised corrections made to the official records. I find that this is an undesirable administrative practice. However, I am satisfied that the revised entry reflected the Neurological Observation Chart recordings, and thus that Mr Brown was attended to immediately after his fall.
v) Notifying the family of the fall several hours later
I found that the hospital acted appropriately and in good faith and advised the family of the fall once the patient's condition began to deteriorate.
4.4 - Delay by the Hospital in signing the Medical Certificate of the Cause of Death
It is unacceptable that there was no record of the patient's death on the hospital's computer system almost two weeks after he died. Nor is it acceptable that the patient's medical records were still on the ward at this time. I am greatly concerned about the time it might have taken to obtain a death certificate, if the complainant had not taken active steps to progress the matter. I find that these actions were based on undesirable administrative practices and are contrary to fair or sound administration, having regard to Sections 4(2)(b)(vi) and (vii) of the Ombudsman Act, 1980.
4.5 - Record Keeping
There was an unacceptable deficit in record management practices in relation to key elements of this particular case by some hospital staff, for example:- the absence of the Maintenance History Records for the ward utilities, the absence of any falls risk assessment of Mr Brown, the unsigned changes that were made to the original entry in the Incident Report Form, the absence of details regarding the management of the remains on the ward before removal to the mortuary, and the unsigned changes that were made to the original entry in the mortuary register. This represents poor practice generally, but also limited the evidence available to me for some aspects of my investigation. I find that some of these actions were the result of carelessness, and others were based on undesirable administrative practices and were otherwise contrary to fair or sound administration, having regard to Sections 4(2)(b)(iii), (vi) and (vii) of the Ombudsman Act, 1980.
4.6 - Advice from Consultant regarding surgery
The complainant and the consultant both have different recollections about the conversation regarding the option of surgery for Mr Brown. In the absence of independent evidence to support this particular aspect of the complaint, I am not in a position to reconcile the two versions of events.
4.7 - CT scan
The decision not to perform a CT scan on arrival at the A/E Department was a clinical decision of the medical staff, following the appropriate liaison with the Consultant Radiologist-on-call. Accordingly, this element of the complaint is outside my remit. The decision to perform a CT scan was made within four hours of the patient's arrival and the scan was completed within 16 hours of his admission. Mr Brown's Consultant Physician was satisfied that this timescale was reasonable given his presenting condition.
4.8 - Skull X-ray
The decision not to conduct the proposed skull X-ray was taken following consultation between medical staff. This is a matter of clinical judgement and accordingly this element of the complaint is outside my remit.
4.9 - Patient's Pyjamas
There was poor communication with the family in relation to the patient's soiled pyjamas. It was inappropriate and insensitive that the patient's soiled pyjamas were left in his bedside locker for 3 days, only to be found there by the family after his death. I find that this was the result of negligence or carelessness, having regard to Section 4(2)(b)(iii) of the Ombudsman Act, 1980.
In advance of finalising my recommendations in respect of this investigation, I sent a draft of my report, which included my draft findings, to the HSE to afford it an opportunity to make observations on the contents. In response, the hospital management accepted there was a number of administrative failings at ward management level and system level in the care and treatment of the late Mr Brown. The hospital apologised unreservedly to the Brown family for these failures.
Hospital management also acknowledged and apologised for the failure of a number of staff to adhere to the hospital policy and advise the Coroner of the death of Mr Brown in a timely fashion. It said that the delay in the notification to the Coroner was not intentional and the subsequent adverse effect on the Brown family is deeply regretted.
In relation to finding 4.1 ( Post-mortem and notification to the Coroner), the HSE advised me that the following measures have been introduced to avoid this breach of hospital policy in the future:
A death notification checklist is also being finalised. This checklist includes:
The HSE confirmed that arrangements are being made at national level to ensure that induction training generally for NCHDs includes protocols for the appropriate notification of patient deaths to the Coroner.
In relation to finding 4.2 (Treatment of the remains and the family on the ward), the hospital management said it regrets that official records to ascertain the length of time that Mr Brown (RIP) remained on the ward after his family had left were not available to my Office. In order to address this deficit, a checklist for staff is being finalised. The HSE told me that the requirement to afford the highest level of dignity to patients nearing the end of life is fully recognised and, in this regard, the hospital participated in a baseline "National Audit of End of Life Care in Hospitals (2008-9)" which was coordinated by the Irish Hospice Foundation. The HSE advised me that, where possible, all patients nearing end of life are afforded privacy in a single room. However it said that, on occasion, clinical and infection control pressures impinge on the availability of single rooms. Hospital management apologised for the breakdown in the communication between the ward staff and the family on this occasion. It confirmed that arrangements have been put in place to alert all staff when a patient has died, advising that they are not to enter the area without consulting the nurse in charge.
In relation to finding 4.3 (The patient's fall), the hospital management acknowledged my findings in relation to the bed side call bell.
It explained that since 2005, the nursing care plan and assessment has been reviewed and a more detailed assessment/care plan has been introduced. Training has also been provided to staff as part of the 'roll out' of the introduction of the new documentation. It explained that the care plan is completed at the time of admission and part of this process incorporates issues of safe environment and mobilisation. A further requirement of this assessment requires verification that the call bell is working, within reach, and that the patient understands its operation. Hospital management acknowledged and apologised for the incomplete maintenance records for the period concerned.
In relation to the bed-side rails, the hospital management accepted that the documentation was absent and that a falls assessment was not completed. It explained that this now comprises part of the patient assessment on admission and it is reviewed, updated and documented throughout the patient stay, as necessary. In addition, Hospital management confirmed that since 2008 a nursing guideline for the use of bed rails has also been introduced and implemented. In relation to the time of the fall, hospital management accepted and acknowledged my findings in relation to the documentation around the time of the fall. As a result, training has been reinforced on an ongoing basis to all nursing staff and a revised guideline on document and record writing has been introduced and implemented.
In relation to finding 4.4 (Delay in signing the Medical Certificate for the Cause of Death), the HSE said that unfortunately, it cannot be verified or established if Ms Brown was given her father's chart by a staff member on the ward and asked to bring it to the Medical Records Department. However, it confirmed that a chart tracking system has since been introduced to assist in ensuring that the Medical Records Department staff members are aware of the location of medical charts. The HSE acknowledged that it is unacceptable that there was a two week delay in transferring the patient's medical record to the consultant's secretary. Hospital management apologised to the family for any adverse impact arising from this delay.
In relation to finding 4.5 (Record Keeping), the hospital management accepted and acknowledged that there were unacceptable deficits in relation to record management practices despite ongoing training for nursing and healthcare staff. Hospital management said it regrets any impact these deficits may have had on my investigation. It explained that these deficits are being addressed.
In relation to finding 4.9 (The patient's pyjamas), the hospital management accepted my findings about the poor communication in relation to the deceased patient's soiled pyjamas. It confirmed that it is currently updating a patient information leaflet which will include information on the management of in-patient personal laundry.
I welcome the HSE's positive response to my Draft Investigation Report on this case and the wide range of improvements the hospital has agreed to, both before and after receipt of it. These improvements, detailed in Chapter 5 of this report, include healthcare record keeping, communication, falls management and post mortem practices; the development of staff training, staff guidelines and patient information leaflets; and the implementation of an action plan for End of Life Care in Hospitals.
I intend to review progress / compliance with these initiatives over time. However, notwithstanding these very positive developments, I make the following recommendations:-
I recommend that Limerick Regional Hospital
I also recommend that
My Investigation Report was issued to the CEO of the HSE in June 2010 and I am satisfied that the HSE has accepted all my recommendations and devised an action plan to implement these in a timely fashion.
Appendix 1 - HSE's Response to Recommendations of Final Report and Action Plan
19 April 2010
Mr Pat Whelan,
Director General,
Office of the Ombudsman,
18 Lower Lesson Street,
Dublin 2
Re; Draft Report and Findings of Ombudsman Ms A V the Mid Western Regional Hospital, Limerick
Dear Mr Whelan,
I refer to your letter of 19 March 2010 to Professor Brendan Drumm, Chief Executive Officer, HSE, concerning the Ombudsman's investigation of the complaint received from Ms A, which has been forwarded to me for attention.
The management of the Mid Western Regional Hospital, Limerick acknowledges receipt of your draft report in relation to the above investigation.
Hospital management accepts that there were a number of administrative failings at ward management and system level in the care and treatment of Mr A (RIP) for which the hospital apologises unreservedly to the family.
In the interim period a number of steps have been taken to address the weaknesses which contributed to such failures with regard to;
A continuous quality improvement cycle underpins our approach to address these issues which includes explicit standards, audit and clarity on roles and responsibility.
4.1 Post Mortem and notification of Coroner
The management of the Mid Western Regional Hospital acknowledges and apologises for the failure of a number of staff to adhere to the hospital policy and advise the coroner of the death of Mr A in a timely fashion, The delay in the notification to the coroner was not intentional and the subsequent adverse affect on the family is deeply regretted.
The following measures have been introduced to avoid this breach of hospital policy in the future.
A death notification checklist and process is also being finalised. This checklist includes;
Arrangements are also being made by the HSE at National level to ensure that induction training generally for non consultant hospital doctors includes protocols for the appropriate notification of patient deaths to the coroner.
4.2 Treatment of the remains and family on the ward
Hospital management regrets that official records to ascertain the length of that Mr A (RIP) remained on the ward after his family had left were not available to the investigator from the office of the Ombudsman. In order to address this deficit a checklist for staff is being finalised.
The requirement to afford the highest level of dignity to patients nearing the end of life is fully recognised and in this regard the hospital participated in a baseline "National Audit of End of Life Care in Hospitals (2008-9)" which was coordinated by the Irish Hospice Foundation. The findings of this audit are due to be published by the Irish Hospice Foundation at the end of April 2010.
The next phase of this programme involves the development of an action plan based on the findings of the "National Audit of End of Life Care in Hospitals (2008-9)" and the "Quality Standards for End of Life Care in Hospitals". Hospital management are committed to the implementation of the action plan as soon as it is developed.
Where possible, all patients nearing end of life are afforded privacy in a single room. However, on occasion, clinical and infection control pressures impinge on the availability of single rooms.
Hospital management wishes to apologise for the breakdown in the communication between the ward staff and the family on this occasion.
Arrangements have been put in place to alert all staff when a patient has died, advising that they are not to enter the area without consulting the nurse in charge.
4.3 The patient's fall
i) The Bed Side Bell
Hospital management acknowledges your findings in regard to the bed side call bell. It was never the intention to either misconstrue the information provided by the Ward Manager or mislead the Ombudsman in relation to the presence of the bed side bell. Hospital management regrets any confusion caused by this inadvertent error in communication in relation to this matter to your investigator.
It is unfortunate that the investigator did not revert to the hospital to seek clarification with regard to the call bell issue following the Ward Manager's response.
It is noted that your investigator reverted to the hospital for subsequent clarification regarding the allegation by one of the nursing staff that the time on the incident form had been altered.
Since 2005, the nursing care plan and assessment has been reviewed and a more detailed assessment / care plan has been introduced. Training has also been provided to staff as part of the 'roll out' of the introduction of the new documentation. The care plan is completed at the time of admission and part of this process incorporates issues of safe environment and mobilisation.
A further requirement of this assessment requires verification that,
This assessment addresses the issue of both the presence and functionality of' the call bell. This is documented in the environmental assessment section of the Nursing Admission and Assessment Form.
Hospital management acknowledge and apologise for the incomplete maintenance records for the period concerned. This deficit in relation to the presence and functionality of the call bell is now addressed, as outlined above, in the environmental assessment at the time of admission.
ii) Observation of the patient's fall
Hospital management accepts and notes your findings in relation to the patient's fall.
iii) Bed Side Rails
Hospital management accepts that the documentation was absent in regard to bed side railings and the fact that a falls assessment was not completed. This now comprises part of the patient assessment on admission and is reviewed, updated, documented throughout the patient stay as necessary.
Since 2008 a nursing guideline for the use of bed rails has also been introduced and implemented.
iv)Time of fall
Hospital management accepts and acknowledges your findings in relation to the documentation around the time of the fall and the unauthorised corrections are noted. Accurate and contemporaneous record keeping is central to the provision of clinical care and in this regard, training has been reinforced on an ongoing basis to all nursing staff. An audit of nursing documentation was completed in 2009.
A guideline on document and record writing has also been implemented
v) Notifying of the family of the fall several hours later.
Hospital Management notes the Ombudsman's acknowledgement of the appropriateness of the actions of the hospital staff in relation to notification to the family of the time of the fall having regard to the time of the first "observations", as recorded on the patient's neurological observation chart.
4.4 Delay by the Hospital in signing the Medical Certificate of the cause of Death
Hospital management wish to inform you that the patient administration system (PAS) was updated at 17.16 hrs on the day of Mr A's death (RIP).
Unfortunately, it cannot be verified or established if Ms A was given her father's chart by a staff member on the ward and asked to bring it to the Medical Records Department as this is the first occasion this matter has been raised. A chart tracking system has since been introduced to assist in ensuring that the Medical Records Department staff members are aware of the location of medical charts.
It is unacceptable that there was a two week delay in transferring the patient's medical record to the consultant secretary and this should not have arisen. Hospital management apologises to the family for any adverse impact arising from this delay.
4.5 Record Keeping
Hospital management accepts and acknowledges that there were unacceptable deficits in relation to record management practices despite ongoing training for nursing and healthcare staff. Hospital management regrets any impact these deficits may have had on your investigation.
The deficits are being addressed as follows:
4.6 Advice from Consultant regarding surgery
Hospital management notes that you are unable to reconcile the two versions of the events and accept your conclusion with.regard to the above.
4.7 CT Scan
Hospital management notes your finding and accepts your conclusion with regard to the provision of a CT scan given Mr A's (RIP) presenting condition.
4.8 Skull X-Ray
Hospital management notes your findings with regard to this matter.
4.9 Patient's Pyjamas
Hospital management accepts your findings in relation to the poor communication in relation to the patient's soiled pyjamas. The hospital is currently updating a patient information leaflet which will include information on the management of in-patient personal laundry. This updated leaflet will be available in May, 2010.
Hospital management hope the above observations are of assistance to you in completing your investigation. However, if you require any further assistance please do not hesitate to contact me.
Yours sincerely,
Laverne McGuinness,
National Director,
Integrated Services Directorate,
Performance & Financial Management
Recommendation Action Plan
Recommendation Action Plan
| Recommendation | Action Plan | Persons Responsibility for Implementation | Timeframe |
Raise awareness and vigilance of medical, nursing and risk management staff to deaths that follow serious incidents. |Set up a Mortality and Morbidity Committee within the Dept of Medicine to facilitate review of patient deaths. Refresher training on incident reporting including patient deaths |Dept of Medicine Administration Head, Assistant Director of Nursing and Business Manager. | Clinical Risk Advisor |February 2011 |
| Ensure that serious incidents are followed with appropriate actions. | Following investigation of a serious incident identify appropriate actions within an agreed timeframe, implement and monitor. | Clinical Line Managers, Consultants, Department Managers and Risk Advisor | November 2010 | |
| Ensure that medical team provide adequate guidance in advance of periods of leave to fully inform on call staff who may be charged with making decisions regarding post mortem. | Draw up a standard operating procedure to facilitate appropriate communication pathways between medical teams out of hours and during periods of leave. | Administration Head Department of Medicine, Clinical Director, Hospital Manager | November 2010 | |
| Review current complaint handling procedures that are consistent with the Health Act (Complaints) 2004 | Regulations (S.I. No.652 of 2006) particularly Article 8 which stipulates, under other issues, the time frame within which a complaint should be investigated and completed. | Review current time frame in relation to complaints processing; the findings will be utilised to facilitate further action as necessary. | Hospitals Manager in association with the Area Manager, Consumer Affairs. | Within 3 months |
| Publishes its complaint examination procedures on its website. | The HSE's Complaints Policy and Procedure Your Service Your Say and documentation is available on hse.ie | Completed | ||
| A member of the senior management team in Limerick Regional to visit the family to apologise in person for the shortcomings identified in this report and to explain what action is being taken on foot of the findings and recommendations contained in the report | As soon as the Office of the Ombudsman issues the final report to the family, the Acute Hospital Manager and Clinical Director will meet with and apologise personally to the family at a time and place suitable to them | Acute and Continuing Care Hospitals Manager and Clinical Director | As soon as the report is issued a visit to the family will be arranged at their convenience | |
| To assist in providing a remedy and closure for the family the findings of this investigation be drawn to the attention of key staff involved in the care of the late Mr A during his stay in the hospital. | The findings of the investigation will be brought to the attention of all staff concerned by way of a debriefing / information session. | Clinical Risk Advisor, Assistant Director of Nursing and Business Manager Department of Medicine. | November 2010 | |
| This investigation report to inform further review and updating of the relevant procedures manuals, data capture processes and infomration systems. | Ongoing review of relevant procedures manuals information systems and data capturing and information systems via Q Pulse implementation. | Department Managers, Risk Advisor, Business Manager, Quality Manager | November 2010 | |
| The Investigation Report to be brought to the attention of the National Director for Quality and Care with a view to all hospitals taking cognisance of key learning points. | Inform the Quality and Directorate of findings and actions taken. | Clinical Director and Hospital Manager | November 2010 |
Appendix 2 - The HSE’s Initial Review Report (Dec 2005)
Appendix 3 - A Post mortem
In certain situations when someone dies in Ireland, it may be necessary to carry out a post mortem examination (also called an autopsy) of the deceased's body. A post mortem examination is a medical examination of a dead body to determine the exact cause of death. In the case of a violent death, the post mortem may be necessary as part of a criminal investigation. Post mortems in Ireland are carried out by a specific type of physician called a 'pathologist'.
The family or next of kin will normally be asked for their permission before a post mortem is carried out. However, where a Coroner has ordered a post mortem examination, the permission of the next of kin is not necessary.
Following the post mortem examination, the body will normally be released to the spouse or next-or-kin immediately after the examination has been completed
Although the need for a post mortem will not usually delay the funeral, the results may not be available until three to eight weeks later. In certain circumstances, it may be several weeks before the post mortem report is received from the pathologist.
A person can discuss the results with the deceased's doctor once the results are available, and one can then proceed with registering the death in the usual way. One cannot register the death until the post mortem results are received by the Coroner's Office. Prior to inquest (or whilst awaiting the post mortem report) the Coroner will provide on request an Interim Certificate of the Fact of Death.
(Reference source: www.citizensinformation.ie )
Appendix 4 - The Coroner
A Coroner in Ireland is an independent official with legal responsibility for the investigation of sudden and unexplained deaths. The role of the Coroner is to enquire into the circumstances of sudden, unexplained, violent and unnatural deaths. This may require a post mortem examination, sometimes followed by an inquest. The post mortem is carried out by a Pathologist, who acts as the Coroner's agent for this purpose. The Coroner's inquiry initially is concerned with establishing whether or not death was due to natural causes.
The Coroner essentially establishes the "who, when, where and how" of unexplained death. A Coroner is not permitted to consider civil or criminal liability; he or she must simply establish the facts. If a death is due to unnatural causes, then an inquest must be held by law. The principal legislation that established the role and responsibilities of Coroners in Ireland is the Coroners Act 1962.
A Coroner will not be involved in cases where a person died from a natural illness or disease for which the deceased was being treated by a doctor within one month prior to death. In this case, the doctor will issue the medical certificate of the cause of death. The death can then be registered and a death certificate can be obtained.
In cases of sudden, unnatural or violent death, there is a legal responsibility on the doctor, registrar of deaths, funeral undertaker, householder and every person in charge of any institution or premises in which the deceased person was residing at the time of his/her death, to report such a death to the Coroner. The death may be reported to a member of An Garda Síochána, not below the rank of sergeant, who will notify the Coroner. However at common law, any person may notify the Coroner of the circumstances of a particular death.
In situations where a medical certificate of the cause of death is not available, the Coroner will arrange for a post mortem examination of the body. If the post mortem examination shows that death was due to natural causes, and there is no need for an inquest, a Coroner's Certificate will be issued to the Registrar of Births and Deaths who will then register the death and issue the death certificate.
If death is due to unnatural causes, the Coroner is obliged to hold an inquest. The death will be registered by means of a Coroner's Certificate when the inquest is concluded (or adjourned in some cases).
Prior to the inquest (or whilst awaiting the post mortem report), the Coroner's office will provide an Interim Certificate of the Fact of Death, which may be acceptable to banks, insurance companies and other institutions.
Deaths reportable to the coroner include the following:
(a) Deaths occurring at home or other place of residence:
(b) Deaths occurring in hospital:
(Source: www.citizensinformation.ie )
Appendix 5 - Sample Copy of the Certificate of the Cause of Death Form
Appendix 6 - Registering a death
It is a legal requirement in Ireland that every death that takes place in the State must be recorded and registered. Records of deaths in Ireland are held in the General Register Office, which is the central civil repository for records relating to Births, Marriages and Deaths in the Republic of Ireland.
A death can be registered with any Registrar, irrespective of where it occurs. Deaths must be registered as soon as possible after the death and no later than three months. It is usually registered by the next of kin.
A doctor must be satisfied about the cause of death before he/she can certify it. If he/she didn't see the deceased at least 28 days before the death occurred, or if he/she isn't satisfied about the cause of death, he/she must inform a Coroner who will decide if a post mortem is necessary. If the deceased died as the result of an accident, or in violent or unexplained circumstances the coroner must be informed. There may be a delay in registering a death where a post mortem is carried out. The death is automatically registered where an inquest or post mortem is held at the request of the Coroner. The Coroner issues a certificate to the Registrar containing all the details to be registered. Deaths should be registered as soon as possible and no later than 3 months from the date of the death.
A death is registered by the Registrar of Births and Deaths for the registration district in which death occurs. A relative or other eligible person must obtain a Medical Certificate of the Cause of Death from the medical practitioner who attended the deceased during the last illness. A death is registered when a qualified informant (often a spouse or next-of-kin) attends at the office of the Registrar of Births and Deaths and provides the following information:
The person registering the death must also produce a Medical Certificate of the Cause of Death signed by a doctor who treated the deceased within one month prior to death. A death is registered in the district in which death occurred and not where the deceased was resident.
Where a death is reported to the coroner and is the subject of a post mortem examination or inquest, registration will be effected by means of a Coroner's Certificate after the post mortem or inquest. The Death Certificate will then be available from the District Registrar's office.
(Source: www.citizensinformation.ie )
Appendix 7 - The Glasgow Coma Scale
The Glasgow Coma Scale (GCS) is a neurological scale which aims to give a reliable, objective way of recording the conscious state of a person. A patient is assessed against the criteria of the scale, and the resulting points give a patient a score between 3 (indicating deep unconsciousness) and 15.
Generally, brain injury is classified as
Severe - with scores of 3-8 (which is the generally accepted definition of a coma)
Moderate - with scores of 9 - 12 and
Minor - with scores greater than 13.
The total score is the sum of the scores in three categories.
The total score is the sum of the scores in three categories.
| Category | Action | Points |
| Eye Opening Response | Spontaneous--open with blinking at baseline | 4 points |
| Opens to verbal command, speech, or shout | 3 points | |
| Opens to pain, not applied to face | 2 points | |
| None | 1 point | |
| Verbal Response | Oriented | 5 points |
| Confused conversation, but able to answer questions | 4 points | |
| Inappropriate responses, words discernible | 3 points | |
| Incomprehensible speech | 2 points | |
| None | 1 point | |
| Motor Response | Obeys commands for movement | 6 points |
| Purposeful movement to painful stimulus | 5 points | |
| Withdraws from pain | 4 points | |
| Abnormal (spastic) flexion, decorticate posture | 3 points | |
| Extensor (rigid) response, decerebrate posture | 2 points | |
| None | 1 point |
(Reference source: www.unc.edu/~rowlett/units/scales/glasgow.htm )
Appendix 8 - Neurological Observations Chart
Neurological observations include assessment of conscious level, vital signs, pupil size and reaction, motor response, and verbal response. These observations are taken at regular intervals and documented / mapped on a chart.