independent review into the circumstances surrounding the
TRANSCRIPT
Independent review into the circumstances surrounding the
discharge, transfer and death of a patient and the HSE’s
responses to and investigations into same
A report for
Health Services Executive
December 2017
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Authors: Peter Killwick Chris Brougham © Verita 2017 Verita is an independent consultancy that specialises in conducting and managing investigations, reviews and inquiries for regulated organisations. This report has been written for Health Services Executive and may not be used, published or reproduced in any way without their express written permission. Verita 338 City Road London, EC1V 2PY Telephone 020 7494 5670 E-mail [email protected] Website www.verita.net
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Contents
Introduction and summary
1. Foreword 4
2. Introduction 7
3. Terms of reference 11
4. Methodology 12
5. Executive summary and recommendations 14
Details of the investigation
6. Decision to discharge and transfer process 22
7. Complaint handling 47
8. National Incident Management Team Report 66
Appendices
Appendix A Team biographies 78
Appendix B Documents reviewed 80
Appendix C Partner B’s questions 82
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1. Foreword
1.1 This is an unusual and difficult investigation for Verita to undertake, in that the
event occurred in November 2007 and has been subject to a number of reviews in
subsequent years. There was an initial complaint investigation in 2007/8 and a HSE
National Incident Management Team (NIMT) review which commenced in December 2010
and concluded in November 2013. Under these circumstances, it is extremely difficult to
identify reliable ‘new’ evidence or, indeed, to question individuals about contentious
details as, quite understandably, specifics may have been forgotten with the passage of
time.
1.2 Having said this, from the outset of our work, the fact that a catastrophic failure in
healthcare occurred has seemed very apparent. At the most basic level, an extremely ill
patient was transferred to a setting where, given their requirements and the equipment
available on the ground, death was inevitable. At Verita, the most fundamental test we
use to judge an incident is that of predictability and preventability. Developed in
conjunction with a leading firm of healthcare lawyers, an incident is termed predictable
if:
“There is evidence that could have alerted professionals that the incident would
occur, even if this evidence had been un-noticed or misunderstood at the time it
occurred.”
And preventable if:
“Professionals had the knowledge, the means and the opportunity to stop the
incident from occurring but didn’t take steps to do so. Simply establishing that
there were actions that could have been taken would not provide evidence of
preventability, as there are always things that could have been done to prevent
any tragedy.”
1.3 In this instance, at the outset of this report we will state unequivocally that the
death of Patient A was both predictable and preventable.
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1.4 Despite the circumstances and the manner of Patient A’s death, a systems analysis
investigation was not immediately commissioned and the information given following the
event to the Coroner did not warrant a post mortem and inquest.
1.5 An Inquest was subsequently held in July 2009, after representations to the
Coroner from Partner B and her legal advisors.
1.6 The HSE first acknowledged (and apologised for) the failure in care provided to
Patient A when a civil claim relating to the event was settled in September 2012.
1.7 In the absence of any immediate systems analysis investigation, Partner B
contacted the Director of Nursing at Hospital X and was advised that, in accordance with
the HSE’s ‘Your service, your say’ policy, she could submit a comment, compliment or
complaint to the complaints officer. She decided on 10 December 2007 to submit a
written complaint. The response to this complaint did not address the matters
complained about, but rather raised more questions for Partner B.
1.8 Following protracted correspondence with the HSE at various levels – local,
regional and national - over the period 2008–2010, the HSE commissioned a National
Incident Management Team (NIMT) review in late 2010 and which reported in November
2013. While some shortcomings in the care process and subsequent management of
Partner B’s complaint were identified in the NIMT 180 Report, it also failed address many
of the concerns of Partner B.
1.9 Given the circumstances and manner of Patient A’s death, Partner B has many
concerns and matters that remain unanswered by the above reports. It has been clear
from the outset of Verita’s involvement that there has been a fundamental breakdown in
trust between Partner B and ‘the system’. In our experience, this is not uncommon when
the initial response to incidents does not satisfy those close to the deceased and (whether
real or perceived), they have to ‘fight’ for further investigation. This is often exacerbated
when the passage of time is interpreted as ‘the system’ trying to ‘cover up’ failure or
protect individuals.
1.10 In writing this report, and at the specific request of the HSE, our work is primarily
directed towards answering the outstanding issues that remain for Partner B. It must also
be stated that this report is not a reinvestigation of Patient A’s case, so only when
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completely necessary do we address issues of fine detail. Rather, we have tried to look at
higher level issues that can bring clarity to Partner B and Patient A’s family and provide
learning for the HSE and its staff.
1.11 We would like to extend our deepest sympathy to Partner B for her loss and
commend her remarkable tenacity in the most difficult of circumstances over the last
nine-plus years. We hope that this investigation report can bring her the closure that she
deserves.
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2. Introduction
2.1 The circumstances of the discharge, transfer and death of Patient A has been
subject to what were termed local and national review and investigation by the HSE and
was examined in a coroner’s court in 2009. The response to the adverse event and the
response to the initial complaint made by Patient A’s partner, Partner B were subject to
further scrutiny within the Terms of Reference for the November 2013 National Incident
Management Team (NIMT) report (NIMT 180).
2.2 The chronology of events contained in NIMT 180 is, we feel, as comprehensive as it
can reasonably be. Partner B has concerns with aspects of this chronology, which we will
address in the relevant sections this report but, given the passage of time, there is no
realistic prospect of us adding to the timings of events, correspondence and interactions
described. On this basis, we do not, in this document, re-state a full chronology of events
leading to Verita’s involvement. Rather, in this introduction, we give a narrative
chronology of what we feel are key events in order to provide context for our
observations. We comment on the interpretation of events when we believe this to be
necessary.
Narrative Chronology
2.3 Patient A was a man with a history of respiratory failure due to idiopathic
pulmonary fibrosis (IPF), first diagnosed in 2001. Between 2001 and 2007, Patient A had
continued to live at home, primarily cared for by his partner, Partner B. It is not in
question that in November 2007, Patient A was at the end stage of his illness.
2.4 On the morning of 21 November, his condition had sharply declined and, after a
home visit by his GP, Medical Practitioner 1, was observed to be in acute respiratory
distress with very low oxygen saturation. Patient A was transferred by ambulance to the
emergency department of Hospital X at 2:30pm that afternoon. On Friday 23 November
2007, Patient A was discharged from Hospital X and transferred by ambulance to
Community Unit Y, a small community nursing unit specialising in the care of elderly
patients. The level of supplemental oxygen required by Patient A was not available at the
Community Unit Y. The ambulance in which Patient A was transferred departed, and he
was pronounced dead within 30 minutes of his arrival.
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2.5 Given that there had been no acknowledgement of an adverse event having
occurred and no indication from the HSE of any investigation despite the circumstances
and the manner of Patient A’s death Partner B rang the director of nursing in Hospital X
approximately one week after the event for guidance on how to proceed. Partner B was
advised to submit a comment, compliment or complaint in accordance with the ‘Your
service, your say’ policy.
2.6 Given the above context, she submitted a written complaint to Hospital X dated 10
December 2007, requesting answers and explanations as to how and why the incident
occurred. Hospital X replied on 12 December 2007, stating that Partner B could expect a
response by 10 January 2008, produced under the organisation’s complaints policy – ‘Your
service, your say’. A written response, dated 29 February 2008, was received by Partner B
on 6 March 2008, some two months after it was first promised.
2.7 Partner B and Patient A’s family considered this response to be fundamentally
flawed, particularly in having errors of factual accuracy and failing to address issues raised
in the letter of complaint. Some specific areas of concern for Partner B and Patient A’s
family were detailed in a letter from Partner B’s solicitor, dated 8 April 2008. The
conclusion of this letter was very direct:
“Our client’s demands of the Health Service Executive are very simple; she
requires the acknowledgement of a complete failure by the Health Service
Executive in their duty of care to the late [Patient A] and a clear an [sic]
unambiguous apology for that lapse”
2.8 Receipt of this letter was received on 11 April from Hospital X, stating that that
they would be in contact in due course.
2.9 On 11 April 2008, Partner B contacted Patient Focus, a patient advocacy service,
outlining her concerns. In reply, Patient Focus replied to Partner B expressing their
sympathy and stating that they believed her complaint to be valid. They advised that she
had the right to appeal the outcome of the complaint and to have an external
investigation conducted by the HSE, asking if the coroner had been notified of the death
and stating that, in their view, a risk management assessment should be completed by the
hospital. [Note - Since this initial exchange, an individual then with Patient Focus but
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since 2011 acting as an independent patient advocate has been supporting Partner B in
her efforts to get the answers that she seeks and have her outstanding concerns
addressed].
2.10 On 2 May 2008, Hospital X wrote to Partner B’s solicitors, suggesting a meeting
between Partner B and Patient A’s family and members of Hospital X staff in order to
discuss the concerns raised in the solicitor letter of 8 April. This suggestion was met with
scepticism by the solicitor, as it was interpreted as a reluctance to acknowledge in writing
any shortcomings or to provide a written apology. This sentiment was communicated to
Partner B on 16 May 2008. In the last week of May 2008, a member of staff from Hospital
X contacted Partner B by telephone to discuss the proposed meeting. A follow-up letter
dated 6 June 2008 restated the proposed attendees and specified that the purpose of the
meeting was to “examine and discuss the care and treatment given to [Patient A] prior to
his discharge to [Community Unit Y] ... in November 2007”. There was no reference to
the specific issues and requirements stated in the 8 April correspondence.
2.11 The solicitor wrote to Partner B on 21 July 2008, restating their lack of confidence
that the meeting would address the stated concerns. This was communicated in a letter
to Hospital X on the same day. This letter was acknowledged on 23 July 2008, and stated
that one of the staff members was on leave until 5 August 2008.
2.12 The proposed meeting never took place. On 15 August Hospital X wrote to Partner
B, stating that:
“We have reviewed the process concerning the transfer of [Patient A], and I wish
to acknowledge problems identified in the transfer process. We sincerely
apologise for these shortcomings. We are in the process of putting measures in
place to ensure that a similar event does not reoccur.”
2.13 There was again no mention of the specific points raised by Partner B’s solicitor in
his letter of 8 April 2008.
2.14 On 2 September 2008, Partner B replied to Hospital X requesting a copy of the
review referred to in the 15 August letter, and asking for details of the “measures you are
putting in place as a result”. Partner B requested an “immediate” response. No reply
had been received by 23 September, at which point Patient Focus wrote to Hospital X
asking when Partner B would be answered.
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2.15 The family received a reply to their 2 September letter in October 2008. This
remained unsatisfactory, as there was no acknowledgement that a serious incident had
occurred, factual inaccuracies in the response had not been corrected and no apology was
offered. Subsequently, following prolonged representations to the HSE at all levels from
Partner B and her advocate throughout 2009 and 2010, the HSE in December 2010 through
its National Incident Management Team commissioned a system analysis investigation. The
final NIMT report was completed in November 2013.
2.16 From the perspective of Partner B and her advocate questions and issues remain
unanswered/unaddressed in relation to Patient A’s care management and, in particular,
decisions taken in relation to the planning and management of his discharge and transfer
to the Community Unit Y, the manner of his death and the HSE’s responses to the incident
both at the time and subsequently. A synopsis of key questions are outlined at the start of
each section of this report, and a full list of questions submitted by Partner B included as
Appendix B.
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3. Terms of reference
3.1 The HSE commissioned an independent review into the circumstances surrounding
the discharge, transfer and death of a patient and the HSE’s responses to and
investigations of his death. The review will cover the period from the patient’s admission
to hospital in 2007 to the date of commissioning of this review.
3.2 The scope of the investigation is given below.
1. To meet with Partner B in order to gain a clear understanding of issues remaining
for her regarding (a) the care management of Patient A particularly in relation to
the planning and management of his discharge and transfer to Community Unit Y,
and the manner of his death there: and (b) the HSE’s responses to the incident
both at the time and subsequently.
2. To assess the extent to which available evidence can be used to address any of the
outstanding issues relating to Patient A’s care and report in relation to these.
3. To assess and address any outstanding issues related to 1 and 2 above and make
any findings/recommendations required.
4. To review the HSEs responses and investigations to date and to determine why they
did not address the concerns of Partner B in a timely and effective manner.
5. To make recommendations to enhance the development of a responsive family
centred process for addressing care concerns.
6. To make any other findings/recommendations identified as required to prevent
recurrence of similar issues occurring in the future.
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4. Methodology
4.1 We met with Partner B to establish the exact nature of her concerns regarding the
decision to discharge Patient A, the planning and execution of the transfer to Community
Unit Y and the care received in Community Unit Y. This formed the foundations of our
assessment as to whether currently available evidence addressed these concerns. During
the meeting, we discussed the areas in which Partner B believed that there were flaws in
the response to her complaint to Hospital X and why the HSE systems analysis investigation
was believed to be inadequate.
4.2 We conducted interviews with senior managerial, medical and a senior nurse
manager in Hospital X, nursing and managerial staff in Community Unit Y, senior HSE staff
who were involved in the events (and their investigation) and a senior manager in the
community team at the time of Patient A’s death. It must be noted that Verita’s brief was
not to re-investigate the incident or the response to the incident from the beginning, but
rather to examine decisions that were made at the time and the method and rationale
behind the responses given where there remains a lack of clarity or consistency.
4.3 In order to assess the standard of care offered, we used Verita investigation
processes, refined over numerous complex investigations with the clinical expertise of Dr
John Costello (see Appendix A for biographies). We believe that this combination of
impeccable clinical expertise and the robustness of the Verita process ensured that our
findings are strong, fair and balanced.
4.4 In writing any report, Verita must base its findings on evidence that can be
corroborated by reliable sources. In this investigation, we accept that, given the passage
of time, individual recollection of events will often be incomplete. On this basis, while
we are happy to draw conclusions based on the balance of probability, we simply state
that if there is not reliable, contemporaneous documentary evidence, we cannot (and will
not) make firm conclusions.
4.5 The specific tasks that we carried out were as follows.
• Met Partner B, in order to explain the purpose, scope and methodology of the
investigation; share the credentials of the investigators; and seek to build a
relationship of trust with her.
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• During this meeting we, established the details of Partner B’s concerns with the
care and management of Patient A, the complaint response and systems
analysis investigation.
• Collected and reviewed documentation relevant to our investigation, including:
• clinical records;
• local and national policies and guidelines;
• documentation pertinent to Partner B’s complaint and the response to it;
• documents pertinent to the systems analysis investigation; and
• where permitted, notes from interviews conducted as part of the systems
analysis investigation.
• Identified and interviewed individuals only where we believed that this would
add clarity to our understanding.
• All interviews were recorded and transcribed to ensure that an accurate and
enduring record is made. Interviewees were given the opportunity to be
accompanied by a friend or representative and to review the transcript for
accuracy.
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5. Executive summary and recommendations
Decision to discharge and transfer process
5.1 The weight of verifiable evidence points to the fact that the decision to discharge
Patient A from Hospital X was taken on the morning of 23 November 2007, without input
from Partner B and Patient A’s family.
5.2 On 23 November 2007, Partner B was in no doubt that Patient A was nearing the
end stage of his illness. She was also fully aware of the severity of the immediate
situation. We provide evidence, however, that this was not more widely understood,
particularly by the ambulance service or by staff in Community Unit Y. This should have
been made clearer by staff at Hospital X. This may well have facilitated better decision-
making around the transfer.
5.3 While we fully support multidisciplinary approaches to patient care, it is vital that
there is an individual ultimately responsible for any individual patient. In this case, we
are equally clear that this ultimate responsibility rested with Medical Practitioner 2. We
have highlighted weaknesses in processes and communication around the decision to
discharge Patient A that undoubtedly contributed to his death.
5.4 If Medical Practitioner 2, as he maintains, was opposed to the transfer, he should
have insisted on the completion of a ‘discharge against medical advice’ form. The fact
that he did not represented poor practice and highlights poor communication with Partner
B and Patient A’s family.
5.5 A particularly troubling aspect of this element of our investigation is the effect on
Partner B of the suggestion that she somehow ‘forced’ the discharge of Patient A to
Community Unit Y. An inevitable consequence of this narrative is that she was culpable in
the death of her partner that she had faithfully and very effectively cared for over a
number of years. The manner and circumstances of Patient A’s death (particularly the
fact that she was outside of the room in Community Unit Y), together with this inference
has, we believe, caused great distress to Partner B. As stated above, the available
evidence shows that the decision to discharge Patient A was effectively taken when
Partner B was not in Hospital X. This is a view shared by the Information Commissioner in
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his judgement of 5 September 2015. It must be stated clearly and unequivocally that
Partner B bears no responsibility for the events of 23 November 2007.
5.6 We cannot speculate as to whether decisions taken on 23 November would have
been different if the results of the blood test taken that morning had been available, but
it represents poor practice on the part of the Hospital X team that Patient A was
discharged without these results. Further, it adds weight to the impression that the
discharge, having been booked with the ambulance service, had an irreversible
momentum.
5.7 The fact that, according to the clinical experts, Patient A was not medically fit for
discharge further highlights the serious weaknesses of systems and processes in place in
Hospital X in November 2007. This should have been recognised by the medical team
caring for Patient A and the transfer stopped.
5.8 The fact that the individual who made the 10:28 call to Community Unit Y cannot
be identified highlights the lack of an effective discharge process and poor documentary
record keeping in place at Hospital X in November 2007. This represents a collective
failure of the team caring for Patient A.
5.9 The incorrect coding of Patient A as a non-urgent transfer constitutes a serious
error on the part of his medical care team in Hospital X.
5.10 The handover of Patient A to the paramedics was clearly deficient but, we believe,
this was predicated on the expectations set by his AS3 (non-urgent) coding. In retrospect,
it is clear that a more detailed handover was necessary, but on the 23 November the
ambulance team were expecting to pick up a patient that required ‘minimal or no
interventions.’ We believe that their actions were commensurate with this. Partner B
and her advocate reasonably ask if the paramedics should not have questioned the AS3
designation of the transfer, but we do not believe that this was their responsibility. The
determination of the nature and timing of the transfer was made by the team with
primary responsibility for, and direct knowledge of, Patient A’s clinical condition, so it is
not the place of individuals lacking in this knowledge (or, indeed, expertise) to question
this.
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5.11 There is no doubt that the circumstances and manner of Patient A’s death at
Community Unit Y was unacceptable in any advanced healthcare system. He suffered
what must have been a horrific death without the dignity one would expect in a modern
healthcare system. Effective planning and communication was absent between the
healthcare professionals charged with the care of Patient A.
5.12 Staff at Community Unit Y were wholly unprepared to meet the care requirements
for a patient with Patient A’s needs. We believe, however, that the Community Unit Y
staff were placed in a very difficult situation by the lack of effective communication prior
to, and during, Patient A’s arrival. Pulmonary medicine is a specialist area that they
would have required detailed instructions to fully understand. This was not provided by
Hospital X and the ambulance paramedics were not in a position to do so. We do not
believe that they could reasonably be expected to understand the implications of a 60%
oxygen prescription in the absence of these instructions. Neither do we believe that
Medical Practitioner 1 could be expected to interpret the oxygen prescription in the
absence of clearer guidance from Hospital X. Again, Partner B and her advocate ask if the
nursing staff at Community Unit Y should have halted the transfer and referred back to
Hospital X before accepting Patient A. Again, though, we do not believe that this is
realistic. As with the paramedics, Patient A’s condition was outside of their area of
expertise, so it is understandable that they might not immediately recognise the severity
of the situation. Events unfolded with such rapidity that there was little or no time for
reflection. We reiterate that the fault lies in the initial decision to discharge Patient A.
Complaint Handling
5.13 We need to be clear at the outset of this section that the death of Patient A should
not have been treated as a complaint, but rather been the subject of an immediate
systems analysis investigation given the nature of the incident and its catastrophic
consequences. There is now a widespread recognition of this.
5.14 Having said this, the fact remains that it was treated as a complaint, so we must
judge the response against this reality.
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5.15 The requirements of the HSE’s complaint handling policy – ‘Your service, your say’
- had been met until early 2008 in terms of the nature of the investigation, the individuals
contacted and timescales for response.
5.16 We are satisfied that the risk advisor providing clinical input to the complaint
response simply reported what she was told by the relevant individuals. At the time, she
would not have reason to doubt the veracity of what she was being told. It has been
established, however, that there were a number of key factual inaccuracies in her input.
5.17 While the complaint response did fall within the six-month limit mandated by the
complaint policy, the communication with Partner B was poor, particularly in the latter
end of the process where several deadlines were missed and commitments not met
without explanation. To this extent, the complaint did not meet the requirements of
‘Your service, your say’.
5.18 At a basic ‘technical’ level, the complaint response is inadequate as it fails to
address the specific issues stated in Partner B’s December 2007 letter. It is also
unacceptable that on a more personal level, given the circumstances and manner of
Patient A’s death, the fact that Partner B had “insisted on bringing him to [Community
Unit Y]” was now being detailed a matter of ‘official’ record. This should never have
happened.
5.19 Partner B is, understandably, deeply sceptical regarding how this response was
arrived at and the veracity of the inputs to it. We share her concerns.
5.20 The complaint response was highly selective in what it said (and did not say,
notwithstanding its factual errors), and did not address the issues raised in Partner B’s
complaint – how were the events on 23 November 2007 possible, and was the healthcare
system at fault.
5.21 Although, as stated, we believe that Partner B’s complaint should have been
immediately identified as a serious incident that required a comprehensive investigation,
we must guard against hindsight bias. It is understandable that, as Partner B’s concerns
were initially submitted to Hospital X as a complaint, this is how they were handled.
While this is now generally accepted to be wrong, it must be viewed in the context of an
immature system where policies and guidance were either lacking or not universally
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understood. Partner B and her advocate do not agree with this conclusion, as it was the
director of nursing in Hospital X who advised Partner B to submit her concerns as a
complaint, and they point out that there was a systems analysis investigation in progress
at the time in Hospital X. While we have sympathy with this view, on balance we have
seen no evidence that there was, effectively, any concerted attempt to ‘cover up’ the
incident through inaction or inadequate action. Partner B and her advocate strongly
dispute the suggestion that the systems and processes around risk management and
complaints in the Mid West Region were, at the time, “immature”. This is examined in
section 7 below.
5.22 Despite very clear indication from Partner B that she believed the original
complaint response to be inadequate, this was not addressed by Hospital X or the HSE in
subsequent correspondence. In addition, the correspondence fails to acknowledge
recognise and accept the factual inaccuracies of the original response.
5.23 Notwithstanding the fact that the death of Patient A should have immediately been
identified as a serious incident requiring a full investigation, the subsequent
administration of Partner B’s complaint provides an object lesson in weak complaint
management. This led to a complete breakdown in confidence in the system on the part
of Partner B but, more damagingly, factual inaccuracies of a most distressing nature were
introduced to the narrative that have not been fully addressed to this day.
National Incident Management Team Report (NIMT 180)
5.24 A systems analysis investigation should have been commissioned immediately after
the death of Patient A. This is now widely recognised, but we do not believe that this was
a result of evasion or any attempt to ‘cover-up’ the circumstances of Patient A’s death.
Rather, we find that it was the result of a series of poor individual decisions taken in a
rapidly evolving system lacking in the required degree of understanding and knowledge.
Partner B and her advocate do not agree with this conclusion, believing that as there was
already a systems analysis investigation underway in Hospital X, the need for one in this
case should have been apparent and they question if pressure to avoid a further
investigation may have been material in the decision-making process. We did not find any
evidence to support this assertion.
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5.25 While there are a small number of minor amendments from the original to final
published version of the terms of reference for the NIMT report, we do not believe these
to be material.
5.26 We are satisfied that the terms of reference for NIMT 180 were appropriate, and
did not unduly preclude any line of investigation. We are equally assured that the lead
investigator explicitly understood this.
5.27 While we saw that some terminology changed over the course of the drafting
process, but see no evidence that the decision to discharge Patient A from Hospital X was
disregarded either through neglect or design. While we agree that, in retrospect, it is
unfortunate that the decision to discharge was not included in the incident description in
earlier drafts of the report, the nature of complex investigation dictates that the text
evolves over time. The fact that discharge was identified as a care delivery problem in
early drafts of the report and addressed in the incident description of the final report
demonstrates that the investigation team was open to suggestion and revision in an
appropriate fashion.
5.28 We are satisfied that the lead investigator for NIMT 180 always took the decisions
to include or exclude information with the best interests of the final report in mind.
Equally, we are satisfied that the investigation team was not placed under inappropriate
pressure to ignore particular lines of inquiry by any individual associated with the
investigation. We were impressed by the clarity and integrity displayed by the lead
investigator in both our face to face interactions and subsequent correspondence. We do
not say this to imply that we would always have made the same decisions as the
investigation team and report authors, but we find no grounds to criticise them in their
decision-making process.
5.29 A natural extension of the finding above is that we do not question whether ‘due
process’ was followed in the production of the report. We found that the lead
investigator was well informed on matters of propriety embedded within the guidance,
and as much as possible followed this. If there was any minor deviation, we are satisfied
that this was inadvertent or predicated on the actions of individual’s peripheral to the
core team.
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5.30 We do not believe that the execution of NIMT 180 was compromised by conflicts of
interest. Rather, we believe that all individuals behaved appropriately for people in their
roles.
Recommendations
R1 In circumstances where clinicians are opposed to discharge for whatever reason,
the HSE should ensure that clinicians routinely complete DAMAs and record the facts in the
medical notes. This is correct practice, and can alert patients, families and carers to the
gravity of the situation and so aid good decision making.
R2 The HSE should take all reasonable steps to ensure that any new guidance policies
and processes are widely publicised and that executive staff in healthcare institutions
monitor knowledge of and adherence to these.
R3 Although the HSE has accepted responsibility for the death of Patient A and made
an appropriate apology, we recommend that a public acknowledgement, if possible in a
format agreed with Partner B should be issued and state ‘on the record’ that the HSE
recognises that the responsibility for the events of November 2007 that led to the death of
Patient A resides exclusively with the healthcare system and that she did not insist on
Patient A’s transfer. It should also state that measures have been put in place to address
the identified failings. This should be done without delay.
R4 The HSE should immediately, and in very plain language, write to Partner B stating
that complaint response of 29 February 2008 was unacceptable and failed to follow the
relevant policies and legislation in place at that time and apologise for the distress that it
caused her at the time, and that it has continued to cause her to this day.
R5 The HSE should assure itself that there is a health system wide process for the
correct triage and identification of serious incidents however they are identified,
particularly if concerns are uncovered as a result of complaints.
R6 If it has not already done so, the HSE should issue clear guidance that
investigations of complaints and serious incidents can proceed in parallel with criminal
investigations.
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R7 As soon as the eligibility of an incident for a systems investigation is established, it
is imperative that a suitable team is identified and that the investigation commences.
R8 The HSE’s Guideline for systems analysis investigation of incidents and complaints,
while never precluding the involvement families and carers of victims of serious incidents,
is not explicit in stating that the views and expectations of these groups should be
considered when writing terms of reference for investigations, and that they should be
supported through the investigation process. The HSE should consider including this in
order to ensure that their concerns are explicitly recognised and addressed.
R9 The action plan resulting from NIMT 180 should be shared with Partner B and her
advocate.
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6. Decision to discharge and transfer process
Outstanding questions regarding the decision to discharge Patient A
• Who was responsible for the decision to discharge Patient A from Hospital X?
• Was Patient A medically fit to be discharged?
• Was an appropriate degree of scrutiny applied to the available facilities in
Community Unit Y prior to the discharge decision, particularly with regard to its
capacity to provide high dose oxygen?
• Who was responsible for making the checks on Community Unit Y?
• What role did Medical Practitioner 1 play in the decision to discharge Patient A
from Hospital X?
• Did the wider clinical and nursing team act appropriately in the decision to
discharge Patient A? Was an appropriate degree of scrutiny applied to the
available facilities in Community Unit Y prior to the discharge decision,
particularly with regard to its capacity to provide high dose oxygen?
• Who was responsible for making the checks on Community Unit Y?
• Were appropriate checks made with Patient A’s respiratory physician prior to
discharge?
• Why was Patient A discharged in the absence of the results of the arterial blood
gas and full blood count tests carried out that morning?
6.1 The decision to discharge Patient A is pivotal to our investigation, as it set in train
the chain of events that led to Patient A’s death.
6.2 On this basis, Verita commissioned the opinion of an eminent consultant physician
in general and respiratory medicine, Dr John Costello. Dr Costello’s biography can be
found in appendix A. We refer to Dr Costello’s expert opinion through this section of the
report.
6.3 It is well documented that there is a strong difference of opinion as to who took
the ultimate decision to discharge Patient A on 23 November 2007. His responsible
clinician in Hospital X, Medical Practitioner 2, has maintained that Patient A’s transfer was
insisted on by Patient A himself, Partner B and Medical Practitioner 1. In interview,
Medical Practitioner 2 told us:
23
“[Partner B] was insisting on taking [Patient A] to [Community Unit Y]”
and
“I spoke with [Patient A] and informed him the wish [sic] of [Patient B] and the
patient agreed for the same”.
6.4 When asked if Medical Practitioner 1 had initiated the transfer, Medical
Practitioner 2 stated:
“Initiated, yes, also [at the] persistent insistence of [Partner B], and agreed by the
patient”
6.5 By contrast, Medical Practitioner 1 quoted correspondence that he had written in
reply to a draft version of NIMT 180 that was shared with him. We believe that this
succinctly states his position:
“[The report] wrongfully attributes the discharge of [Patient A] to a ‘request’
from me that ‘a transfer be completed as soon as possible’. I wish to emphasise
that I did not request his discharge at any stage on that fateful day. I was
presented with a fait accompli by [Medical Practitioner 2], who insisted that no
more could be done for him in the assumed absence of infection or thrombosis. I
requested that [Patient A] be seen by the palliative care team ... before discharge
but this was also declined or, as we are now told, unavailable on that Friday.
6.6 Medical Practitioner 1 does accept that he agreed to the transfer of Patient A on 23
November, but that this was due to his unavailability on 24 November:
“My conversation with [Medical Practitioner 2] was that, if there is no treatable
infection, if you feel that he doesn’t need admission to intensive care, then we
would consider a transfer back to the palliative care bed - if he was absolutely
sure that nothing more could be done.
He then conceded that he might be prepared to keep him an extra night, Friday
night, and I said that the problem was that it was the weekend and that I
wouldn’t be there tomorrow to receive him.
24
The transfer was then put in place. [Patient A] was duly transferred back to the
palliative care unit at [Community Unit Y] on the afternoon of 23 November.
6.7 The suggestion that Partner B had been advocating for the transfer has been
strenuously denied by Partner B throughout this process, and in her many statements
subsequent to Patient A’s death.
6.8 As we have stated, we do not believe (given the passage of time) that there is any
realistic prospect of any party changing their recollections of the events of the day of
Patient A’s discharge. On this basis, we cannot comment on individual conversations on
the 23 November 2007. Rather, we will revert to facts that are not in dispute by any
party.
6.9 At 10:22am a call was placed from the switchboard of Hospital X to the ambulance
service, booking a transfer for Patient A to Community Unit Y.
6.10 At 10:28 am, a 67 second call was made from Hospital X to Community Unit Y,
advising them that Patient A would be transferred to Community Unit Y at an unspecified
time later that day. It is reported that Community Unit Y requested that they should be
informed when Patient A left Hospital X.
6.11 It is not disputed that Partner B was not present in Hospital X when these calls
were made. When asked to explain his assertion that the decision to transfer was made
later that afternoon (after the reported conversation with Partner B) in light of this
apparent contradiction, Medical Practitioner 2 said:
“I was not involved in organising the ambulance service. Phoning the ambulance is
usually done by the nursing staff, because they have to organise their work, they
predict who might go home. Once they received the call from the general
practitioner, and when they handover, the GP’s letter, and everything was there,
probably they already phoned the Ambulance in order to organise the work.”
6.12 Medical Practitioner 2 went on to say:
“I believe the sister in charge received a call from the GP. After that probably,
she, or her staff, or anybody from the ward, phoned the Ambulance Service, but
25
no decision has made definitely at that time because I received the call from my
[senior house officer] that they had received a call from the general practitioner
for the discharge, and I said, no decision will be made until I see the patient.”
Comment
There is a great deal of dispute over the nature of the conversations that took place
on 23 November 2007. Individuals are adhering to their stated recollections of these.
This is entirely understandable and, of course, expected. We will, therefore, not try
to second-guess what ‘might’ have happened. Rather, we will base our findings on
what we know to be true.
Finding
F1 The weight of verifiable evidence points to the fact that the decision to discharge
Patient A from Hospital X was taken on the morning of 23 November 2007 without input
from Partner B and Patient A’s family. It is a matter of record that calls were made to the
ambulance service to arrange the transfer and to Community Unit Y to inform them of
Patient A’s arrival before Partner B arrived at the hospital. It is noteworthy that the
Information Commissioner agrees with our interpretation of events, stating in his
judgement of 5 September 2015 that:
“I am satisfied that the material before me provides a sufficient basis to conclude
that the applicant has satisfied the onus of proof in this case, and demonstrated
that, on the balance of probabilities, the statement [that Partner B insisted on the
transfer of Patient A] is incorrect and misleading.”
The key importance of this finding is made clear in finding F6 below.
6.13 Medical Practitioner 2 has maintained throughout this, and preceding,
investigations into the death of Patient A that his advice to all parties was that the
discharge should never have occurred.
26
6.14 When asked in interview if he counselled against the transfer. He replied “yes”. It
is Partner B’s firm assertion that Patient A did not wish to discharge himself, and never
made such a request.
6.15 Clearly, it is not the place of a facility such as Hospital X to hold patients against
their will. While it is the absolute right of patients to discharge themselves at any
juncture, under these circumstances it is normal that clinicians should make their
objections very clear and ensure that a discharge against medical advice (DAMA) form
should be completed.
6.16 We asked Medical Practitioner 2 why, in this case, he had not completed a DAMA.
He said:
“Yes, it could be considered at that time the way they insisted. Probably I could
have proposed it.”
6.17 He went on to say:
“That’s the one option you could consider, but I didn’t think that was probably
necessary at that time. Even in retrospect, I don’t think so. Going patient to
[Community Unit Y] [sic] by DAMA would not change the outcome.”
Comment
This a troubling statement by Medical Practitioner 2. While self-evidently true –
even if a DAMA had been signed and the transfer gone ahead, the outcome would
have been the same – we believe that this points to a poor adherence to policy and
procedure and, equally, a poor level of communication between staff at Hospital X
and Partner B.
Finding
F2 If Medical Practitioner 2, as he maintains, was opposed to the transfer, he should
have insisted on the completion of a DAMA. The fact that he did not represented poor
27
practice and highlights poor communication with Partner B and Patient A’s family and
within the medical team.
6.18 For the reasons already stated, we will not try to second-guess specific
conversations in November 2007, but it is clear that, from when the idea was first
suggested, there was a significant lack of clarity as to why Patient A was going to
Community Unit Y. Initially, health service staff generally believed this to be for
palliative care. Partner B and Patient A’s family believed that, when the idea was first
suggested, it was to offer Partner B a period of respite from her carer duties. By 23
November 2007, however, it was very clear to partner B that the situation had changed.
Her advocate wrote that:
“Partner B was fully aware of the gravity of Patient A’s condition on Friday 23rd
November 2007 and that everything had changed from the time of his sudden
deterioration on the morning of 21st November 2007.
The decision to discharge Patient A from Hospital X made no sense to her. She
had no illusions about 'respite care' on that day. She was fully aware that their
home oxygen unit could no longer provide for his needs having watched the oxygen
flow-valve during his 2-day stay in Hospital X. However, she had assumed given
their expertise that the relevant medical personnel had everything under control
and had established that Community Unit Y could provide the level of oxygen he
required.”
6.19 This is in stark contrast to the understanding of staff at Community Unit Y, who (as
discussed more fully below), still believed that respite for Partner B was a primary factor
in the transfer.
6.20 In his submission, our medical expert, Dr Costello stated:
“[There was] a lack of definition of his clinical status, in particular where the
dividing line lay between terminal/palliative care and active
intervention/intensive care and this is evident even from the GP referral letter.
At no point in the records I have received can I see a note on a decision about his
resuscitation status, and I think this reflects this. [Patient A] had the end stage of
28
an aggressive illness which responds poorly to treatment and no matter what had
happened on that day, had only a very short time to live. Nevertheless, the
events surrounding his death, and in particular the distressing nature of oxygen
lack, for him and for his family and partner who witnessed all of this, was severe.
It is my view that decisions should have been made earlier in his management,
certainly at the time of his final admission to hospital, that this was the end stage
of an untreatable condition and that pursuing aggressive active intervention would
not have been appropriate and that he should not have been a candidate for
resuscitation and possible intubation and mechanical ventilation in intensive care.
This would have caused him unnecessary distress and might have meant a
prolonged period on a mechanical ventilator with little prospect of successful
extubation and any quality of life thereafter. Had these problems been
addressed, then the situation that arose and the poor decision making and
communications in his transfer to [Community Unit Y] might well have been
avoided. It is of note that his clinical status had been identified by [Medical
Practitioner 3] in her letter of 8.10.2007. In particular, she recommends the use
of sedative/narcotic agents to alleviate his breathlessness, and this is a
recommendation we would make only in patients at the terminal end of this
condition, so she had correctly pinpointed the advanced stage of his disease.”
6.21 On the subject of communication, our medical expert, Dr Costello, stated:
“The responsibility for transmitting this information lies with the medical staff, in
particular, [Medical Practitioner 2] and from my reading of the records there did
not seem to be any systematic provision for the management of communications
and relationships with the family.”
Finding
F3 The severity of Patient A’s condition should have been made clearer to Partner B
by staff at Hospital X, primarily Medical Practitioner 2.
29
Recommendation
R1 In circumstances where clinicians are opposed to discharge for whatever reason,
the HSE should ensure that clinicians routinely complete DAMAs and record the facts in the
medical notes. This is correct practice, and can alert patients, families and carers to the
gravity of the situation and so aid good decision making.
6.22 For a clinical perspective, we asked Dr Costello for his views on the discharge
process. He said:
“[Patient A’s] discharge and transfer took place in rather hurried and muddled
circumstances and, certainly retrospectively, it is my view that he should never
have been transferred in his condition of terminal respiratory failure to an
institution that had inadequate provisions for his management.
“Problems were not identified and noted in relation to his discharge, in particular
the need for high flow oxygen. Although there appears to have been discussion
with the [Medical Practitioner 2], there appears to have been no definitive
evidence in the records that he actually made the decision in terms of his
discharge.” [Verita emphasis]
6.23 Dr Costello further stated:
“[Medical Practitioner 1] clearly knew [Patient A] very well but it is not his job to
discharge him from inpatient hospital care; whilst he should be available for
advice and background, the responsibility for the care of [Patient A] lies with
[Medical Practitioner 2] in the hospital under whose care he was admitted; it does
seem that undue attention was paid to the letter requesting admission to
[Hospital X] and, in particular, the placement of [Patient A] at [Community Unit
Y].”
6.24 When asked where the decision to discharge should lie, Dr Costello was clear:
“The person who holds the ultimate responsibility for [Patient A’s] discharge is
[Medical Practitioner 2].”
30
6.25 We asked Medical Practitioner 2 in interview if he was aware of the policies and
processes in place for the discharge of extremely unwell patients in 2007. He told us:
“I cannot answer that. It would probably be hospital admin or the health board
who would be able to answer [that].”
6.26 When asked what process he did, then, follow, he told us:
“Usually the looking after the patient is the responsibility of all healthcare
professionals in that I am a part. I make a decision along with discussion with
other staff, relatives, and the patient themselves. It varies with the condition of
the patient.”
6.27 The Medical Council of Ireland is clear about a doctor’s accountability to his / her
patients. In its Eight domains of good professional practice, it states:
“Patient safety and quality of patient care should be at the core of the health
service delivery that a doctor provides. A doctor needs to be accountable to their
professional body, to the organisation in which they work, to the Medical Council
and to their patients thereby ensuring the patients whom they serve receive the
best possible care.”
and
“Medical practitioners must co-operate with colleagues and work effectively with
healthcare professionals from other disciplines and teams. He/she should ensure
that there are clear lines of communication and systems of accountability in place
among team members to protect patients.”
6.28 In its Guide to professional conduct and ethics for registered medical
practitioners, the Medical Council states:
“When you delegate or refer you must give sufficient information about the
patient and their treatment to the clinicians continuing the care of the patient.
You should take reasonable steps to make sure that the person to whom you
31
delegate or refer has the qualifications, experience, knowledge and skills to give
the care needed.”
and
“When you hand over care for a patient to another healthcare professional, team
and/or partnership institution, you should check that they understand and accept
responsibility for the patient’s care. You should pass on all relevant information
about the patient and the patient’s care. When discharging patients back to
primary care, you should give all relevant information promptly.”
6.29 We fully accept and recognise that the Medical Council advice post-dates
November 2007, but are equally sure that that it simply states a position that should have
been recognised by medical professionals at the time.
Comment
Our clinical expert is clear that the ultimate responsibility for any patient lies with
the consultant in charge of the case. Medical Practitioner 2 appears to take a more
collaborative view. While it is normal (and entirely appropriate) that a
multidisciplinary team approach should be taken in making clinical decisions, it is
equally important that there is a clear, well-understood line of responsibility in
decision-making. This is made clear in the Medical Council of Ireland guidance. In the
absence of a final arbiter, there is the obvious danger that important decisions will
be taken at an inappropriate level in the organisation or, indeed, not taken at all.
6.30 We have reviewed the document HSE code of practice for integrated discharge
planning (November 2008) and found it to be a clear, comprehensive and well-written
document. It states:
“The hospital consultant has continuing clinical and professional responsibility for
patients under his/ her care and each member of the multi-disciplinary team has a
key leadership role to play with regard to their area of expertise within the
team.” [Verita emphasis]
32
Findings
F4 Had this code of practice been in place in November 2007, and followed by the
staff at Hospital X, the tragedy of Patient A’s death should have been avoided.
F5 While we fully support multidisciplinary approaches to patient care, it is vital that
there is an individual ultimately responsible for any individual patient. In this case, we
are equally clear that this ultimate responsibility rested with Medical Practitioner 2. We
have highlighted weaknesses in processes and communication around the decision to
discharge Patient A that undoubtedly contributed to the circumstances and manner of his
death that afternoon.
6.31 We asked Medical Practitioner 2 if he was aware of any changes in policy around
patient transfer after Patient A’s death. He was unaware of the 2008 code of practice.
6.32 In follow-up correspondence between Medical practitioner 2 and Verita, we were,
however, told:
“I would like to mention that I am aware of the document HSE code of procedure
for integrated discharge planning (November 2008) and the integrated care
Guidance (2014) replaced the existing HSE integrated discharge planning.”
6.33 We asked a senior Nurse manager in Hospital X to comment on whether a
collaborative approach was indeed taken in the decision to discharge patients. We were
told that:
“In the past, the whole process was more ‘consultant-led’, but even then,
consultants would confer with experienced nursing staff for advice and insight.
[Now], the ultimate determination as to whether the patient is discharged will
happen on the day, with the ultimate responsibility resting with the patients’
named consultant. This has always been the case.”
33
Recommendation
R2 The HSE should take all reasonable steps to ensure that any new guidance, policies
and processes are widely publicised and that executive staff in healthcare institutions
monitor knowledge of and adherence to these.
Finding
F6 A particularly troubling aspect of this element of our investigation is the effect on
Partner B of the suggestion that she somehow ‘forced’ the discharge of Patient A to
Community Unit Y. An inevitable consequence of this narrative is that she was culpable in
the death of her partner that she had faithfully and very effectively cared for over a
number of years. We believe that this inference, taken in conjunction with the manner of
Patient A’s death, has caused great distress to Partner B. As stated above, the available
evidence shows that the decision to discharge Patient A was effectively taken when
Partner B was not in Hospital X. This is a view shared by the Information Commissioner in
his judgement of 5 September 2015. It must be stated clearly and unequivocally that
Partner B bears no responsibility for the events of 23 November 2007.
Recommendation
R3 Although the HSE has accepted responsibility for the death of Patient A and made
an appropriate apology, we recommend that a public acknowledgement, if possible in a
format agreed with Partner B should be issued and state ‘on the record’ that the HSE
recognises that the responsibility for the events of November 2007 that led to the death of
Patient A resides exclusively with the healthcare system and that she did not insist on
Patient A’s transfer. It should also state that measures have been put in place to address
the identified failings. This should be done without delay.
6.34 We now examine the question as to where the responsibility lay for checking that
Community Unit Y had the necessary facilities to accept a patient in Patient A’s condition,
particularly with regard to its capacity to provide high dose oxygen.
34
6.35 When we questioned Medical Practitioner 2 as to whether he made any checks on
the facilities that were going to be available in Community Unit Y prior to the transfer, he
told us:
“No. I did not make any direct contact with [Community Unit Y] by myself. I
made [a] phone call to [Medical Practitioner 1].”
6.36 He went on to say:
“I didn’t phone [Community Unit Y] and I have no idea what oxygen facilities were
available at [Community Unit Y] at that time.”
6.37 We asked with whom he believed the responsibility for checking the suitability of
facilities in Community Unit Y lay. He said:
“[This] is carried out by nursing staff or clerical staff on the ward.”
6.38 Dr Costello told us:
“…the final decisions about the transfer…, and the logistics and arrangements for
the transfer, must rest with the healthcare team, as their training, knowledge and
expertise should equip them to make the correct judgements in acute clinical
circumstances.”
Comment
It is clear that senior staff cannot, and should not, be expected to make ‘logistical’
arrangements for every patient. It is equally clear, however, that junior medical,
nursing or clerical staff must have clear guidance on what needs to be established in
order to maintain patient safety. This necessitates good communication within
teams and a strong discharge planning process.
35
6.39 We asked the HSE to provide us with the relevant policies in place at the time of
Patient A’s discharge. The Admission policy of the outreach palliative care support beds
states:
“Persons with non-malignancies in the terminal stage of their illness requiring
palliative care may also be admitted to the unit following discussions with the
appropriate Matron”
and
“A detailed clinical assessment must be undertaken by the referring doctor and be
submitted to the unit Matron /Nurse in Charge prior to admission.”
6.40 In the case of Patient A, it is clear that there were insufficient “discussions with
the appropriate Matron” at Community Unit Y, and that a “detailed clinical assessment”
of Patient A was not supplied to Community Unit Y.
6.41 It is not clear whether the “referring doctor” in Patient A’s case was considered to
be Medical Practitioner 1 or Medical Practitioner 2. Medical Practitioner 2 told us:
“I thought [Medical Practitioner 1] should know – there might be an omission from
his part. I believe that. I believe that [Medical Practitioner 1] should have known
the requirements, treatment-wise.”
6.42 While Medical Practitioner 1 said:
“The delivery and prescription of oxygen is not a matter for me as the patient’s
GP and there should be no ambiguity about the established dose and
requirements, or indeed the delivery following handover.”
6.43 Medical Practitioner 1 did, however, confirm to us that:
“The nursing staff at [Community Unit Y] did speak to me about the oxygen
concentrator, either on Thursday 22, or the morning of the 23 November, among
other aspects of [Patient A’s] ongoing care requirements.”
36
6.44 While we have sympathy for Medical Practitioner 1’s assertion that the delivery of
oxygen is not within the scope of a GP’s expertise, we equally understand that there is no
definition of the ‘referring doctor’ in the admissions policy, so this is open to
interpretation. We simply note that, in the absence of more detailed guidance, the
healthcare system failed Patient A in not making the appropriate checks on the facilities
at Community Unit Y. We are clear, however, that the ultimate responsibility for the
safety of the patient lies with Medical Practitioner 2. We note, however, that the 2008
HSE code of practice for integrated discharge planning addresses this point:
“Two-way communication between the hospital and the GP and other Primary,
Community and Continuing Care service providers, as appropriate, shall be
arranged to ensure such services are available and in place for the patient to use
when needed post discharge.”
6.45 When we asked Medical Practitioner 2 if he had contacted Patient A’s respiratory
physician prior to discharge, he told us:
“I advised the team to get information, as you know, from [Medical Practitioner
3], who was his respiratory physician.”
and
“I received the faxed letter from [Medical Practitioner 3] received at 1 o’clock,
13.05 hours.”
6.46 We have seen a fax received by Hospital X in November 2007 containing a letter
from Medical Practitioner 3. This was dated 8 October and sent to Medical Practitioner 1.
While the date is obscured, the time stamp is 15:05 for page 1 and 15:06 for page 2.
There is a handwritten note from Medical Practitioner 1 on the top of the fax, so this is
clearly not the fax referred to by Medical Practitioner 2 as arriving at 13:05 on 23
November. It is perfectly possible that Medical Practitioner 3 re-sent this communication
to Hospital X, as it was her most up to date knowledge of Patient A, but we have seen no
reliable evidence that the communication between Hospital X and Medical Practitioner 3
referred to by Medical Practitioner 2 actually occurred.
37
Finding
F7 In the absence of any proof to the contrary (either documentary or in evidence
gathered by the HSE), on the balance of probability we believe that the Hospital X team
was relying on the fax sent by Medical Practitioner 1 for Medical Practitioner 3 opinion
rather than direct contact on 23 November. We equally accept, however, that while it
would have been good practice to consult with Medical Practitioner 3 prior to discharge,
the fax did contain the most up do date knowledge on the part of Medical Practitioner 3.
We cannot speculate as to whether Medical Practitioner 3 would have advised the Hospital
X as to any particular course of action, nor would it be appropriate to ask Medical
Practitioner 3 to do so.
We have taken the view, however, that this line of questioning is not central to the
events of that day. We have argued that Patient A was in Hospital X, that his condition
could clearly be assessed and that the decision to discharge was effectively taken by
10:22am on 23 November and that this decision was wrong, so do not believe that it would
yield any further benefit (or final resolution, given the passage of time) to pursue this
issue.
6.47 It is a matter of record that Patient A was discharged without the results of the
arterial blood gas and full blood count tests carried out on the morning of 23 November.
This is attributed to the breakdown of the blood gas analyser in Hospital X.
6.48 When the results did become available, they showed a deterioration in Patient A’s
arterial oxygenation and a rise in his white cell count.
6.49 Dr Costello told us:
“The results of the most recent blood count and arterial blood gases should always
be available before the discharge takes place, to establish whether there had
been any recent deterioration that might influence that decision.”
38
Finding
F8 Again, we cannot speculate as to whether decisions taken on 23 November would
have been different if the test results had been available, but it represents poor practice
on the part of Medical Practitioner 2 and his team that Patient A was discharged without
these results.
6.50 We note that the HSE code of practice for integrated discharge planning (November
2008) states:
“Before discharging, the Nurses (or HSCPs/Others) should have carried out a
holistic assessment of the patient, which should include ensuring all relevant test
results have been obtained.”
6.51 We refer to finding F4 above, and further encourage the HSE to satisfy themselves
that the 2008 guidance is being followed across HSE facilities.
Outstanding questions regarding the transfer of Patient A
• Should Patient A’s transfer have gone ahead on 23 November?
• Who booked the transfer of Patient A?
• Who took the decision to categorise the transfer as ‘non-urgent’?
• Were appropriate handovers undertaken at Hospital X and Community Unit Y?
• Who was responsible for ensuring the patients safety in the transfer process?
• What role should Medical Practitioner 1 have played in making checks on
Community Unit Y?
6.52 With respect to whether Patient A should have been transferred to Community Unit
Y, we believe that this question was clearly answered in NIMT 180, in which the
independent expert is quoted as stating:
“…the patient was not medically fit for ambulance transfer to [Community Unit Y]
on the 23rd November 2007.”
39
6.53 This sentiment is echoed by Dr Costello, who when asked if it was appropriate to
transfer Patient A said:
“No, and the outcome bears testimony to this.”
Finding
F9 The fact that, according to the clinical experts, Patient A was not medically fit for
discharge further highlights the weaknesses of systems and processes in place in Hospital X
in November 2007. This should have been recognised by the medical team caring for
Patient A and the transfer stopped.
6.54 We recognise that the HSE has taken steps to put policies and procedures in place
to prevent such occurrences happening today. In section 8 (Key tasks on day of discharge)
of the HSE code of practice for integrated discharge planning’ (November 2008), it states:
“On the day of discharge, the patient should be ready to leave the hospital at the
agreed time and the patient/carer/receiving healthcare facility should have
sufficient information to guarantee continuity of care. Good integrated discharge
planning practices suggest that on the day of discharge all arrangements for PCCC
services should have been put in place and very little new information should be
imparted to the patient or carer.”
The first point made in section 8 is:
“The patient should be confirmed as clinically fit and safe for discharge.”
6.55 An enduring question for Partner B has been who from Hospital X called Community
Unit Y at on the morning of 23 November. We will state now that this question will, with
a high degree of certainty, never be answered.
6.56 We will explore the response to Partner B’s complaint in more detail in section 7
below, but will quote here the member of staff who provided clinical input for the
complaint response. She told us:
40
“At the time, I spoke to [Hospital X] to glean that information. When I spoke to
[member of staff a Community Unit Y], she was the person who told me that she
received the phone call … we did try to find out who made the phone call, [but
had no success].”
6.57 The inability to identify the individual who made the 10:28 am call was confirmed
by the NIMT 180 investigation team:
“Despite interviewing the clinical staff involved the individual who made this
telephone call could not be identified.”
6.58 While we fully understand why Partner B would like to establish who made the call,
all we can state with some degree of certainty is that this was likely to be a relatively
junior member of staff, given what we heard around the collaborative nature of the
Hospital X team. On this basis, we believe that the more fundamental question is why
there was a lack of effective communication both within Hospital X and outward to
Community Unit Y, establishing what needed to be communicated.
Finding
F10 Given the passage of time, there is no realistic prospect of identifying the
individual who made the call at 10:28am to Community Unit Y. While this is regrettable,
we believe that the more pertinent issue is why the individual was not aware of the
necessity to effectively communicate the severity and precise nature of Patient A’s
condition.
6.59 As discussed above, the team at Hospital X reportedly took a collaborative
approach to decision making. As we also stated, this is perfectly acceptable practice, but
there must be an individual ultimately responsible for the care of any patient.
41
Finding
F11 The fact that the individual who made the 10:28 call to Community Unit Y cannot
be identified highlights the lack of an effective discharge process in place at Hospital X in
November 2007. This represents a collective failure of the medical team caring for
Patient A.
6.60 Patient A was designated as a “non-urgent” (AS3) transfer by the team in Hospital
X – described by ambulance staff as “an uncomplicated patient with minimal or no
interventions required” (NIMT 180).
6.61 We stated in finding F9 above that we do not believe that it was appropriate to
transfer Patient A out of Hospital X in his condition. Notwithstanding this, it appears that
the critical state of Patient A’s health was not effectively communicated through his care
team, as he was clearly not ‘an uncomplicated patient’.
Finding
F12 The incorrect coding of Patient A as a non-urgent transfer constitutes a serious
error on the part of his medical care team in Hospital X.
6.62 It is a matter of record that the handover between nursing staff at Hospital X and
the ambulance paramedics was, at best, minimal. This was confirmed by ambulance staff
interviews and submissions for NIMT 180. It was reported by the paramedics that Patient
A’s notes were handed to them in a sealed envelope and that this was ‘not unusual’ for
non-urgent transfers.
6.63 Partner B and her advocate quite reasonably ask if the paramedics should have
questioned the AS3 designation. Indeed, one of the ambulance crew told the NIMT team
that “in hindsight she would have questioned taking [Patient A] out of [Hospital X].”
Another stated, however that “This was a routine patient transfer. Nothing unusual
happened.”
42
6.64 Given these conflicting positions, we do not believe that there is any utility in re-
interviewing the individuals involved. It is self-evident that, in hindsight, questioning the
AS3 designation would have been prudent, but at the time this did not happen, and is not
a reason for censure. Hospital X staff, with a much better understanding of the patient,
determined that patient A should be transferred as an AS3.
6.65 Not having received an adequate clinical handover from Hospital X staff when
collecting Patient A, it was an inevitable consequence that ambulance paramedics could
not provide staff in Community Unit Y with an appropriate briefing when they arrived.
6.66 In addition, the transfer of Patient A was interrupted by the collection of a second
patient, due for transfer to another HSE facility. Partner B reports that this both caused
Patient A considerable discomfort and distress (due to cold conditions on the day) when
the ambulance doors were left open prior to departing Hospital X to collect the second
patient and extended the normal journey time. AS3 transfers can accommodate up to
three patients in one vehicle, so the collection of a second patient was in line with
guidance.
Comment
Designating Patient A as an AS3 transfer inevitably set expectations on the part of
ambulance staff as to the state of Patient A’s health. While it was clearly wrong
that no nurse handover occurred in Hospital X, the seriousness of Patient A’s
situation was obscured by his non-urgent description. Had he have been given a
coding commensurate with his condition, it is likely that greater attention would
have been paid to Patient A’s handover to the ambulance paramedics, and it could
have been decided that it was appropriate for a member of his Hospital X care team
to escort him in the ambulance to Community Unit Y or to stop the proposed transfer.
Partner B asked why the ambulance team did not question the transfer status when
they arrived to collect Patient A but, we believe, this fell outside of their remit.
Clearly, the clinical status of Patient A was best known to his care team in Hospital
X, so a paramedic arriving to effect a transfer could not reasonably be expected to
‘second guess’ their judgement.
43
Findings
F13 The coding of Patient A’s status as AS3 was wrong. As stated in F12 above, in and
of itself, this was poor practice. In addition, we believe that the consequences of this
incorrect coding were a contributory factor in the inadequate transfer process which was
then followed by the patients’ ordeal and death.
F14 The handover of Patient A to the paramedics was clearly deficient but, we believe,
this was predicated on the expectations set by his AS3 coding. In retrospect, it is clear
that a more detailed handover was necessary, but on the 23 November the ambulance
team were expecting to pick up a patient that required “minimal or no interventions.”
We believe that their actions were commensurate with this.
6.67 Again, it is a matter of record that, on arrival at Community Unit Y, there was
minimal discussion between the paramedics and the Community Unit Y nursing staff.
6.68 It is clear that a detailed handover would not have been possible, as the
ambulance paramedic team were not appropriately briefed in Hospital X.
6.69 As a result of the AS3 coding, the paramedic team had another patient waiting in
the ambulance for onward transport. They took the view that they should continue with
their onward journey as soon as Patient A had been placed in the hands of the nursing
team at Community Unit Y.
6.70 We will discuss in more detail how much the Community Unit Y team knew about
Patient A’s condition and care needs in the next section of this report, but it is clear that
they were wholly unprepared to receive a man with Patient A’s requirements.
6.71 We asked a manager at Community Unit Y on 23 November 2007 why Patient A was
being referred to Community Unit Y. She told us:
“…to give [Partner B] respite because she had been looking after him. This was
from [Medical Practitioner 1’s] point of view. This is what he told me.”
44
6.72 It was clear to Community Unit Y staff that Patient A was being transferred from
Hospital X after a period as an inpatient. When asked to comment on her understanding
as to why the transfer was occurring on that day, she said:
“I presumed he would have been stabilised from his acute phase in [Hospital X],
then when he was stabilised he was brought here to continue the process until
such time as he could go home.”
6.73 On the critical issue as to whether they had information regarding Patient A’s
oxygen requirement prior to his arrival, she said:
“No, there was none, I specifically asked on the phone and I specifically told the
person, which unfortunately I didn’t get her name, that we only had an oxygen
concentrator that delivered five litres max.”
6.74 It is now clear that, in reality, the discharge notes faxed to Community Unit Y prior
to Patient A’s arrival did have an attached prescription stating, ‘Oxygen 60%’
6.75 To place the significance of this in context, we asked the manager what function
Community Unit Y serves. She said:
“We are an elderly care residential unit and we have two palliative beds.”
6.76 We asked Dr Costello for his views on this. He told us:
“It is likely that in Community Unit Y, their expectations of having a patient as
acutely unwell with an undefined resuscitation status and requiring high flow
oxygen had not been discussed with them and they were not expecting this, nor
would I criticise them for this; it is the duty of the referring hospital to tell them
in advance of the patient’s needs.”
6.77 We asked Medical Practitioner 1 for his views on the interpretation of the discharge
summary and prescription, and whether he should have played a more active role in
preparing Community Unit Y staff for the realities of Patient A’s condition. He told us:
“I wasn’t managing the oxygen prescription at any stage for [Patient A]. I don’t
think we should be involved in managing the oxygen.”
45
6.78 He went on to say:
“I would repeat that, even though I have trained in hospital medicine and internal
medicine, I hold membership of the Royal College of Physicians, I would not be
happy to prescribe or to be in charge of prescribing oxygen to that level of
requirement. That can only be done through a respiratory consultant. On the
prescription sheet, there is a list of his medications but, up at the top left-hand
corner, there is ‘oxygen 60 per cent’. You would need to know about that, and
what 60 per cent meant. The 60 per cent actually means 15 litres. I did not know
that, to my regret. When a prescription is made, it is basically brought here to
transcribe the drugs but not the oxygen. The oxygen, we have nothing to do with.
As far as I was concerned, [Patient A] was on an oxygen machine and there was an
oxygen machine up at the unit.”
Finding
F15 There is no doubt that the circumstances and manner of death of Patient A at
Community Unit Y was unacceptable in any advanced healthcare system. Effective
planning and communication was absent between all the healthcare professionals charged
with the care of Patient A.
F16 The staff at Community Unit Y were wholly unprepared to meet the care
requirements for a patient with Patient A’s needs. We believe, however, that Community
Unit Y staff were placed in an impossible situation by the lack of effective communication
prior to, and during, Patient A’s arrival. Pulmonary medicine is a specialist area that they
would have required detailed instructions to fully understand. This was not provided by
Hospital X and the ambulance paramedics were not in a position to do so. We do not
believe that they could reasonably be expected to understand the implications of a 60 per
cent oxygen prescription in the absence of these instructions. Neither do we believe that
Medical Practitioner 1 could be expected to interpret the oxygen prescription in the
absence of clearer guidance from Hospital X.
46
We do not say this in any way to minimise the degree to which the healthcare system
failed Patient A. We believe, however, that staff at Community Unit Y were simply the
last link in this chain of systemic failure.
Overarching section Finding
F17 It is not possible to identify any aspect of the health system that emerges with any
credit in the initial decision to discharge Patient A and then in the subsequent
mismanagement of the transfer process. As we have detailed above, there was a
collective failure of communication, exacerbated by poor understanding of (and, as a
consequence, adherence to) proper process. The result was catastrophic.
In conducting this investigation, we have witnessed shock and remorse from every
individual that we interviewed, and a real commitment to ensure that a similar incident
does not recur. The HSE has developed a strong range of policies to support improvements
in discharge planning and processes. Critical to these are more effective communications
across all involved organisations. The effective implementation of these policies is key.
47
7. Complaint handling
Note for reader
Partner B and her advocate have expressed concerns regarding potential failures in
relation to compliance with legislation governing notification of the Gardaí of the
incident, the preservation of the scene of the incident and the general attitude of many
HSE employees, some at senior levels, toward Patient A’s death and their efforts to have
their concerns addressed.
From today’s perspective, it is clear that the Gardaí should have been notified and that
the room should have remained untouched. We do not believe that there is any utility in
stating anything more than this – the decisions made at the time were wrong. In this
section, we will explore the decision to treat the incident as a complaint (and not, as
would have been appropriate, as a serious incident requiring a full investigation).
Where possible, we will include testimony as to the attitude of staff, but we do not
believe that we can reasonably comment on the contemporaneous attitude of staff given
the passage of time.
Comment
Throughout this work, we have gained the impression that individuals perceive
investigations as having negative personal implications rather than providing an
opportunity to learn from mistakes. While we also heard that this negative
perception is improving, we would encourage the HSE to reinforce a more positive
learning culture around the objectives and philosophy of serious incident
investigations.
7.1 As was described in the narrative chronology above, Partner B submitted a written
complaint, dated 10 December 2007 as directed following a telephone call to Hospital X on
29 November 2007.
7.2 In this letter (addressed to the hospital manager of Hospital X), she:
48
a. Gave a brief description of the events on 23 November 2007, including a
harrowing description of Patient A’s final moments in Community Unit Y
b. Asked specific questions around:
i. Was Patient A fit to be discharged?
ii. Why was Medical Practitioner 3 not consulted prior to Patient A’s
discharge?
iii. What instructions were given to the ambulance staff undertaking
Patient A’s transfer?
c. In addition, she expressed concerns over the demeanour of the ambulance
staff during Patient A’s transfer to Community Unit Y
d. She finished the letter by stating, “We, the family of the late [Patient A],
expect you to furnish us with a comprehensive and satisfactory report as to
why this happened to your patient, and our beloved partner and father.”
7.3 This complaint was addressed by staff at Hospital X under the HSE’s complaint
management policy, ‘Your service, your say’. This policy mandates the timescales and
form of response required. It says:
• an acknowledgement letter must be sent within 5 working days of receipt of the
complaint;
• the complaints officer must endeavour to investigate and conclude the complaint
within 30 working days of it being acknowledged;
• if the investigation cannot be investigated and concluded within 30 working days
then the complaints officer must communicate this to the complainant and the
relevant service/staff member within 30 working days of acknowledging the
complaint and give an indication of the time it will take to complete the
investigation;
• the complaints officer must update the complainant and the relevant staff/service
member every 20 working days; and
• the complaints officer must endeavour to investigate complaints within 30 working
days. However, where the 30 working days timeframe cannot be met despite every
best effort, complaints officers must endeavour to conclude the investigation of
the complaint within 6 months of the receipt of the complaint.
49
7.4 Hospital X responded to Partner B’s letter on 12 December 2007. It took the
correct form, as mandated by the policy and informed Partner B that she could expect a
response by 10 January 2008, i.e. within the 30-day timeframe. On the same day, Hospital
X wrote to the ambulance service and Medical Practitioner 2, attaching the letter of
complaint and asking for their response.
7.5 On 8 January, Hospital X wrote to Partner B explaining that they were awaiting
input from the ambulance service and Medical Practitioner 2, and so requested an
extension of the response deadline until 24 January 2008.
7.6 On the 9 and 11 of January 2008, Hospital X received the written responses to the
request from the ambulance service and Medical Practitioner 2 respectively.
7.7 On 8 January 2008, the incident report form from Community Unit Y was received
by the risk advisor responsible for Community Unit Y. We asked her in interview what her
role was at the time of the incident. She told us:
“It was a new department that was being set up at the time and we were the first
risk advisors in the department. My remit at the time was 0.5 the acute services
and 0.5 the community services, so my remit to [Hospital X] at the time was a 0.5
whole time equivalent. We didn’t have integrated risk management way back
then. Our first national guidance came in September 2008. Our quality and risk
framework was 2009 so we were very much flying solo and I think fair to say we
were very reactionary at the time. …the first few years of my job were incident
reporting, trying to change the culture of incident reporting, trying to get people
to report incidents, so that was a lot of the work we did.”
7.8 On her specific role in the response to Partner B’s complaint, she told us:
“If there was a clinical element [to complaints], I would then go and see if I could
support it somehow. I will have read the complaint, seen that there was an issue
about the transfer, gone away and done my first submission, my first single pager
which was not an investigation. It was very much just my comment on the clinical
aspect of the complaint.”
50
Comment
We will assess whether it was appropriate for Partner B’s letter to be treated under
the HSE’s complaint policy later in this section, but the reality is that it was.
Finding
F18 The requirements of ‘Your service, your say’ had been endeavoured to be met until
early 2008 in terms of the nature of the investigation, the individuals consulted and
timescales for response.
7.9 On 23 January 2008, a report was issued to the manager of Hospital X by the risk
advisor providing a brief chronology of events from 21 to 23 November 2007, including
information on Patient A’s reported oxygen saturations and delivery methods. We
comment on the content of this document later in this section.
Comment
Given that the complaint response was due the next day (24 January) and that the
risk advisors input to this was required, it must have been plain at this point that the
timescales promised for the response would not be met. This should have been
communicated to Partner B.
7.10 Having received neither the complaint response nor an explanation as to why (now
in breach of ‘Your service, your say’ requirements), Partner B wrote to the hospital
manager on 1 February 2008, requesting a response within 10 days. The hospital manager
replied in a letter dated 6 February 2008, stating that “a report will be issued shortly.”
7.11 In the period from 7 to 29 February admin staff in Hospital X continued to gather
submissions to support the complaint response, including seeking clarification from
Medical Practitioner 2 concerning Patient A’s oxygen requirements while in Hospital X.
51
7.12 The risk advisor provided a further submission (dated 21 February) to the team
handling the complaint, in which she gave a more narrative version of Patient A’s stay in
Hospital X, events surrounding his discharge and oxygen requirements while in Hospital X.
7.13 The risk advisor could not recall the chain of events between her January and
February submissions.
7.14 A notable element from Medical Practitioner 2’s submission was that:
“His [Patient A’s] oxygen saturation was maintained around 90% through 6-8 litres
of oxygen through mask. Kept his oxygen saturation around 90%.”
7.15 This statement was subsequently retracted and revised as a result of questions
from the NIMT 180 team to read:
“His oxygen saturation maintained around 90% by giving 6-15 litres of oxygen
through nasal canulae or face mask.”
7.16 When we asked Medical Practitioner 2 the cause of this factual inaccuracy in his
submission to the complaint investigation, he told us that this was due to a
misunderstanding with nursing notes, but that this later submission was correct.
Finding
F19 While it is surprising that Medical Practitioner 2 did not verify this significant
information provided to the complaints team, Medical Practitioner 2 is clear that this was
a misunderstanding in transcription. Notwithstanding this, whether 6-8 litres or 6-15 litres
was correct, the oxygen concentrator in Community Unit Y was unable to meet even the
lower (6 litre) level. It had a maximum capacity of 5 litres per minute.
7.17 Notable elements of the risk advisor’s submission include that:
• “[Community Unit Y] use an oxygen concentrator which is capable of
delivering 21% oxygen therapy at a maximum flow rate of 5-6 litres per
minute.”
52
• “It is clearly documented in the medical case notes that [Medical
Practitioner 1] wanted [Patient A] to be transferred to [Community Unit Y],
that [Patient A’s] partner insisted on bringing him to [Community Unit Y]
and that [Patient A] himself indicated that he was feeling better and would
like to go to [Community Unit Y].”
• “There is no prescription for oxygen therapy in the discharge summary.”
7.18 We now know all of these statements to be incorrect. When we asked the risk
advisor as to how this incorrect information was gathered, she told us:
“At the time, I spoke to [Hospital X] to glean that information that I have just
spoken to you about.”
7.19 And:
“I know in the second submission I spoke about the delivery of oxygen through an
oxygen concentrator and some of my information that I put in there was
inaccurate, but it was information that I was given when I sought the
information.”
Comment
The risk advisor was very clear that she was not undertaking the complaint response
herself, but rather providing clinical background to inform it, as she understood was
appropriate for her role. In retrospect, it is clear that much of the intelligence that
she gathered was incorrect. Notwithstanding this, the decision as to what to include
from her January and February 2007 submissions was not her decision, but rather
that of the complaint handling team.
Finding
F20 It would be easy to criticise the risk advisor for the errors in her submissions to the
complaint response. Patient A’s case was, however, in a clinical area that was,
understandably, outside her area of expertise. On this basis, we are satisfied that she
53
simply reported what she was told by the relevant individuals. At the time, she would not
have reason to doubt the veracity of what she was being told.
7.20 On 29 February, Partner B had still not received the response to her complaint, nor
an explanation as to why. She wrote an email to the regional health office, stating her
dissatisfaction with the failure of Hospital X to adhere to their promises or ‘Your service,
your say’ guidance. This email was acknowledged on the same day, stating that Partner
B’s complaint had been escalated to the area manager for consumer affairs. After further
exchanges in the subsequent days, the complaint response (dated 29 February 2008) was
received by Partner B by post on 6 March.
Finding
F21 While the response did fall within the six-month limit mandated by the complaint
policy, the communication with Partner B was poor, particularly in the latter end of the
process where several deadlines were missed and commitments not met without
explanation. To this extent, the complaint did not meet the requirements of ‘Your
service, your say’.
7.21 The complaint response from the Hospital X hospital manager was deeply troubling
for Partner B and Patient A’s family. A number of the factual inaccuracies were found in
the response, most particularly verbatim copies of the statements shown in 7.17 above. In
addition, the response also contained other evidence of a poor grasp of the facts, such as
an incorrect spelling of Medical Practitioner 1’s name and the lack of an acknowledgement
of an adverse event having occurred and an apology.
7.22 The response referenced details of the conversation between Hospital X and
Community Unit Y at 10:28 on November 23. This was subsequently called into question
by the inability of any investigation to identify who made the call to Community Unit Y.
7.23 We reference section 7.2 above, in which the specific areas of complaint are
listed. It is notable that none of these are referenced in the complaint response.
54
7.24 The response does not acknowledge that an adverse incident occurred or apologise
for the incident – only the fact that the response was delayed.
7.25 The response does not acknowledge or recognise any failings on 23 November 2007,
but simply states that “the need to review the standard format of the discharge summary
and the staff training needs around oxygen therapy have been identified as priority areas
for our attention and will be given due attention.”
Comment
It is widely accepted best practice that, in the handling of complaints, the most basic
requirement is to answer the issues raised. This response fails to do so. The fact
that no failures are identified, accepted and apologised for is, in our view,
inexplicable.
Findings
F22 The complaint response failed to meet the standards required by HSE policy and
was inadequate as it failed to address the specifics of Partner B’s December 2007 letter. It
was also factually inaccurate. Given the manner and circumstances of Patient A’s death,
the fact that Partner B had “insisted on bringing him to [Community Unit Y]” also was now
a matter of ‘official’ record was totally unacceptable.
F23 Partner B is, understandably, deeply sceptical regarding how this response was
arrived at and the veracity of the inputs to it. Given the issues with the response
identified above, we share her concerns. It is a common theme in our work of this type
that, when the initial response from ‘the system’ is inadequate, the belief grows in the
complainant’s mind that there is an underlying cause, i.e. the conviction that the
individuals involved are ‘protecting their own’. The term ‘cover up’ is often used.
There are troubling aspects to this case. It is a matter of record that submissions to the
various investigation teams have changed, and it is incongruous that the risk advisor was
able to identify the details of the 10:28am telephone call between Hospital X and
Community Unit Y, but not the person who made it. Were a different approach to the
55
initial investigation taken at the time, it is possible that these questions would have been
addressed. Nine years later, this will not be the case. Our own work has not identified
anything in the paper records or interviews that would suggest a systematic cover up of
the facts. Rather, we find evidence of a poorly executed complaint response, in which
fact checking was weak and the execution of a process without any of the necessary
checks and balances to identify these before a response was issued.
The complaint response was highly selective in what it said and did not say
(notwithstanding its factual errors), and does not address the central issue – how were the
events on 23 November 2007 possible, and was the healthcare system at fault.
7.26 We asked the manager of Hospital X for his views on the way that the incident was
handled. He told us:
“[Partner B] has not been dealt with as appropriately as she should have. I think
we all accept that and there’s also probably a lot of errors through the course of
what happened.”
7.27 When we asked about the process that would have been followed in answering the
complaint, he told us:
“At that stage, it was basically a layman’s complaint process where the layman
would write to the medics looking for a response and we had no way of reviewing
it. That is the way it was done, that was right across the hospital system at the
time, you were dependent upon the clinical personnel to give you the response
back. There was no peer review, there was no one else to look at it and review
it.”
7.28 On the role of the risk advisors and complaints managers at the time, he said:
“They simply faithfully report those things which are presented as facts.” [The
complaints manager] would more likely draft most of the responses, then I would
review them and read them before I would send them out. It is what’s come back
from the relevant consultant, who has all the medical knowledge that I don’t
have.”
56
7.29 In terms of involving the community services in the response, we were told:
“[We concentrated] on the hospital because we were a standalone service. There
was a differentiation between the community services and the hospital services.”
7.30 When asked of the extent of the community services involvement, we were told:
“[We were liaising with] community services – [they were] certainly aware of the
incident. [The belief was that] primarily, most of the issues were hospital based.”
7.31 This belief was supported by a senior community services manager, who told us
that her understanding was that the investigation was being undertaken by acute services
and not in the community.
7.32 In response to being asked if he (the manager of hospital X) was subjected to any
outside influence in deciding whether to initiate a systems analysis investigation, we were
told:
“There was no outside influence. Whether we made the right or wrong decisions,
we made those decisions ourselves. We didn’t [make] them for any untoward
reason. It would be very easy for me to say… ‘yes, I was told by [external
influencer], don’t do any more of it’, but it’s not the case. If there was more that
we could or should have done and were aware of it, we would have done it.”
7.33 Summarising the incident, the then Manager of Hospital X told us:
“Partner B could not have insisted he [Patient A] was discharged. He would have
had to discharge himself against medical advice and that’s not my understanding
what happened. He was discharged by [Medical Practitioner 2’s] team. His name
was over the bed. He is therefore responsible for all of it.
“I am quite adamant, I am not trying to hide, or obfuscate, or deduct from an
element of responsibility for the way it was handled. …in hindsight, clearly, we
would probably be doing it differently if we had in place then what we have in
place now, but we didn’t.”
57
Recommendation
R4 The HSE should immediately, and in very plain language, write to Partner B stating
that complaint response of 29 February 2008 was unacceptable and failed to follow the
relevant policies and legislation in place at that time and apologise for the distress that it
caused her at the time, and that it has continued to cause her to this day.
7.34 After considering the complaint response, the next formal communication between
Partner B and Hospital X was via a letter send by Partner B’s solicitors, dated 21 May 2008,
to the hospital manager. In it, the solicitor makes clear the distress that the complaint
response caused Partner B, points out that the only apology contained in it is the delayed
response and points out the factual inaccuracies of the response. It goes on to highlight
her concerns with the ambulance transfer and asks why an oxygen therapy system was
installed in Community Unit Y within a week of Patient A’s death. As well as the demand
for an unambiguous apology, it goes on to say: “Our client has asked us to indicate that
such an acknowledgement and apology will be acceptable to her and [Patient A’s] family,
provided it is received by us forthwith and in straightforward, unambiguous terms.”
7.35 At this point, the tone of this letter suggests that, while Partner B was obviously
(given the circumstances and manner of Patient A’s death) angry and disappointed with
the complaint response, there was still the opportunity to recover the situation if prompt
action were taken.
7.36 Partner B questions why a full systems analysis investigation was not commissioned
when her original complaint was submitted, particularly as there was an ongoing systems
analysis investigation in Hospital X at the time.
7.37 We asked the manager of Hospital X this question. He told us:
“We did our own systems analysis review here in the hospital. We developed our
own quality improvement plan out of that, specifically for the hospital though.
7.38 When we asked if there was any liaison with the community team, we were told:
58
“Yes. The [community services manager] felt it was a hospital issue, in the main it
probably was other than there was a GP initially involved in it and there was the
nursing home who received the patient. However, primarily most of the issues
were hospital based.”
7.39 We asked the hospital manager why, in his opinion, the death of Patient A did not
lead to a wider, more systemic investigation, particularly given the precedent set by the
ongoing investigation in Hospital X at the same time. We were told:
“[Patient A], from a very early stage involved a Coroner, DPP, Gardaí, Medical
Council, Bord Altranais. There were so many people all over it from a very early
stage and [hospital Solicitor] was quite explicit to me, ‘It is up to you to say, you
have to stop now’. I won’t say he has retracted it, but doesn’t remember saying it,
but I guarantee you I did not come up with this on my own”
7.40 We further asked why the ongoing systems analysis investigation was, prima facie,
given significantly greater attention that that of Patient A, including Health Information
and Quality Authority (HIQA) involvement. We were told:
“I think that the [systems analysis investigation going on at the time of Patient A’s
death] on its own would not have led to the HIQA investigation in its own right.
The fact that there were two other press cases – there were three I have been told
across two different surgeons and there was also a review of about eight different
cases. That called for a different investigation.”
7.41 In retrospect, it seems apparent that the death of Patient A should have resulted in
an immediate systems analysis investigation, given the seriousness of the incident and the
opportunities for learning and improvement it presented.
7.42 We were told by multiple interviewees, however, that the complaints and serious
incident processes were undergoing changes in 2007, with new guidance and processes
being introduced.
7.43 This assertion is vigorously contested by Partner B and her advocate. In the
interest of balance, we believe that their position should be clearly set out. Below are
extracts from a letter from Partner B’s advocate to Verita dated 23 October 2017:
59
“The NIMT Review, having acknowledged the inadequacy and inaccuracy of the HSE
response appeared to explain it as a mere failure due to a lack of clarity, rather
than as something more worrying. They then took the line which, in the two
drafts to date, appears to be followed by Verita - that the Risk Management
system and complaints systems in the Mid West at that time were “immature” and
maybe not widely understood and that this somehow explains the lack of clarity
and excuses the failure.
The indisputable fact here is that HSE did not appropriately investigate this
adverse event or the complaint. The NIMT’s and Verita’s attempt to explain
and/or excuse this is tantamount to acknowledging this fact. We are referring
here to the subsidiary issue of why it was not appropriately investigated.
Logically, in our view, this was either because of a total failure to, unwillingness
to, or a refusal to investigate. NIMT appeared and Verita now appear to be
endorsing the view that it was a failure and to attribute this to the ‘immature
system’.
…we would like to challenge in some detail the claims re the ‘immature system’.
I refer you to the Strategy Document published in 2005 by the HSE Mid West
[Healthcare Risk Management Strategy JUNE 2005 considered by Verita in compiling
this report]. If you read this document you will see that it gives a totally different
impression than that portrayed by Verita and NIMT.”
7.44 The letter then extracts points from the strategy document. For example, the
letter states:
“3: The Healthcare Risk Dept. carried out the education and training of staff
throughout the HSE Mid West Area on Healthcare Risk Management and on incident
reporting. The Services of an external agency had been engaged to undertake
workshops on root cause analysis.”
7.45 The advocate comments:
“This flies in the face of the argument that there was a lack of training as I think
the NIMT tried to portray. Appropriate staff appeared to have received
appropriate training so this cannot be an excuse.”
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7.46 The letter concludes by stating:
“In light of all of the above how can anyone justify an argument of an immature
system or one that was not widely understood? We will never accept that
argument in light of the above and my working knowledge of the HSE at the
time.”
7.47 In response to the points raised by partner B and her advocate, we have
reconsidered the HSE’s Mid-Western Area Healthcare Risk Management Strategy JUNE
2005.
7.48 At the highest level, a strategy document is defined by the Oxford English
Dictionary as, “A document outlining a plan, scheme, or course of action, especially of a
long-term or ambitious nature, typically for a business or other organisation.”
Comment
By any common definition or understanding, a strategy document sets out an
aspirational vision for the future. Indeed, the HSE’s Mid-Western Area Healthcare
Risk Management Strategy JUNE 2005 describes its ‘Strategic Statement of Purpose
and Intent’, ‘Approach to Strategy Formation’ and ‘Implementation of the Strategy’.
We believe that referencing this document as reflective of the reality on the ground
in the Mid Western region at the time has little merit or basis in fact. In complex
systems, the fact that a document stating strategic intent was not fully implemented
over the course of 18 months is, while regrettable, unremarkable.
7.49 When we consider the source material (i.e. the strategy document itself), the
passages summarised by the advocate in 7.39 above actually state:
“2.1.1.11. Education and training for staff on Healthcare Risk Management has
been carried out by the Healthcare Risk Department throughout the HSE Mid
Western Area.
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2.1.1.12. Education and training for staff on incident reporting was also
undertaken by the Healthcare Risk Department.
2.1.1.13. Risk Assessment and Profiling and Root Cause Analysis workshops have
commenced. Services of an external agency were engaged to undertake these
workshops”
Comment
The advocate has taken selective elements of the full text and presented these in
such a way as to suggest that full training has been delivered throughout the Mid
West region. While we accept that the document from June 2005 does describe
elements of progress made in the areas of risk management, there is no detail
provided as to the extent of this progress or what this means in operational practice.
7.50 While Partner B’s advocate references “my working knowledge of the HSE at the
time” as stated, his perspective is not supported by any individual interviewed over the
course of this investigation, whether from Hospital X, community services or the HSE.
7.51 As one example of ongoing changes (an “immature system”), we were told by a
senior community services manager that they could state with certainty that there was no
official policy for escalation of serious incidents to senior managers in late 2007, as they
changed job at end of June 2008 and, in a subsequent role, worked on the escalation
policy. It was her recollection that this policy was formally implemented in 2010.
Comment
Partner B and her advocate maintain that there was a developed system around
serious incidents and the appropriate response to them in the Mid West region at the
time of Patient A’s death. We can find no evidence that this was the case. Indeed,
the strong weight of evidence and testimony is that the opposite is true. The fact
that another systems analysis investigation was ongoing in Hospital X at the time
does not, in our opinion, undermine this conclusion. In our experience over numerous
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investigations, it is common to witness ‘patchy’ implementation of policies and
process, even within the same institution.
Findings
F24 Although it is easy to argue that Partner B’s complaint should have been
immediately identified as a serious incident that required a comprehensive investigation,
we must guard against hindsight bias. It is understandable that, as Partner B’s concerns
were initially submitted as a complaint, this is how they were handled. While this is now
generally accepted to be wrong, it must be viewed in the context of an immature system
where policies and guidance were either lacking or not well understood.
F25 When the letter was submitted by Partner B’s solicitor, it should have been clear
that by treating her concerns as a complaint had totally failed to answer her questions,
had not acknowledged an adverse event had occurred and that significant patient safety
issues remained. This was another missed opportunity to immediately commission a full
systems analysis investigation.
7.52 We heard from several of our interviewees that, if a similar incident were to occur
now, a systems analysis investigation would be undertaken. For example, the risk advisor
said:
“[Now] we have systems and processes in place, we are so much more
knowledgeable and we have serious reportable events, so we have a whole process
where straightaway it [a systems analysis investigation] would have kicked in.
Back then it didn’t really, but when it became the subject of a complaint I
thought it would be dealt with through the complaints process.”
7.53 We have no reason to doubt this statement to be true, and have seen strong,
comprehensive guidance from the HSE, such as the ‘Safety incident management policy’
(2014) and the ‘Serious incident management policy and procedure’. Both are very clear
that:
“It is the policy of the Health Service Executive (HSE) that all safety incidents are
identified, reported and investigated.”
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Comment
It would have been expected that people with knowledge of Patient A’s case would
recognise the importance of identifying, and correctly investigating, serious
incidents. It is common in our investigative work, however, to find that good policies
and guidance are in place, but that individuals on the ground are not aware of it or
simply do not follow it.
Recommendation
R5 The HSE should assure itself that there is a health system wide process for the
correct triage and identification of serious incidents however they are identified,
particularly if concerns are uncovered as a result of complaints.
7.54 The response to Partner B’s solicitor letter was the suggestion of a meeting
between Hospital X staff and Partner B. This was offered in a telephone call on 11 April
2008. This was followed up with a letter on 2 May 2008.
7.55 Partner B responded by asking who would attend the meeting and what its purpose
would be. She was advised (on 6 June 2008) that the attendees would be Medical
Practitioner 1, the hospital manager, ward manager and clinical risk manager. Its purpose
would be “to examine and discuss the care and treatment given prior to discharge to
[Community Unit Y].”
7.56 Partner B responded via her solicitor, on 21 July, stating that her concerns were
not only around the period “prior to discharge”, and referencing the concerns stated in
the solicitor letter of 8 April. The proposed meeting never took place.
7.57 On 15 August 2008, the Hospital X hospital manager wrote to Partner B. The letter
stated, “We have reviewed the process concerning the transfer of [Patient A], and I wish
to acknowledge problems identified in the transfer process. We sincerely apologise for
64
these shortcomings.” It went on to say that, “We are in the process of putting measures
in place to ensure that a similar event does not reoccur.”
Comment
It is notable that, although recognising ‘problems’, this letter does not state in any
detail what they were, and still fails to address the specific issues raised by Partner
B in her complaint or the demands made in the solicitor letter of 21 May.
Finding
F26 For the same reasons stated in finding F22 above, we view this letter of 15 August
wholly inadequate. In addition, it fails to recognise and accept the factual inaccuracies of
the original response and still fails to address the issues detailed in the complaint.
7.58 On 2 September 2008, Partner B wrote to the hospital manager requesting a copy
of the review and details of the measures put in place. She received a reply on 7 October
2008, comprising a covering letter giving a brief outline of the complaint response process,
stating the risk advisors’ recommendations around discharge summaries and oxygen
therapy. A brief overview of the actions taken as a result of these recommendations was
provided. Enclosed were the risk advisor’s comments of 23 January 2008, the risk
advisor’s comments of 21 February 2008 and Guidelines for oxygen administration (25
September 2008).
7.59 Partner B remained deeply dissatisfied with this response. This is unsurprising,
given that it revealed the source of much of the factual inaccuracy seen in the original
complaint response to be the reports provided by the risk advisor. She was also alarmed
that the oxygen guidelines made no mention of concentrators which were central to the
events of 23 November 2007.
65
Events leading to the commissioning of NIMT 180
7.60 The period from this last correspondence from the Hospital X hospital manager in
2008 until the requirement for an independent investigation was agreed by the HSE
regional director of operations (resulting in NIMT 180) on 11 June 2010 can be typified as
one where Partner B and her advocate made representations to a number of bodies,
including (HIQA), HSE, the head of quality and risk, HSE and the Office of the Ombudsman.
During the same period, she was liaising with the Medical Records Office at Hospital X,
seeking the release of Patient A’s medical records and made her representation to the
Information Commissioner.
7.61 Partner B and her advocate remained ‘disappointed’ with their perceived attitude
of the HSE at national level. They state that:
“This has been our experience ongoing with the HSE. The people at national level
surely could see that a systems analysis was required, but declined to issue
directions. More poor decision making given the evidence we provided them
with.”
7.62 A verdict of medical misadventure was reached by a jury at the coroner’s inquest
on 16 July 2009. It should be noted that the factual inaccuracies of the original complaint
report were presented to the coroner by Medical Practioner 2.
Overarching finding of the management of Partner B’s complaint
F27 Notwithstanding the fact that the death of Patient A should have immediately been
identified as a serious incident requiring a full investigation, the subsequent
administration of Partner B’s complaint provides an object lesson in weak complaint
management. A number of the mistakes made are documented above. The response
provided was in breach of policy and legislation in place at that time. This was most
unfair to Partner B. These led to a complete breakdown in confidence in the system on
the part of Partner B but, more damagingly, factual inaccuracies of a most distressing
nature were introduced to the narrative that have not been fully addressed to this day.
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8. National Incident Management Team Report
Outstanding questions regarding the National Incident Management Report
• Did the report answer its terms of reference?
• Did these terms of reference change over the course of the work?
• Was the decision to discharge Patient A appropriately addressed in the report?
• Was there any attempt to disregard the decision to discharge from the report?
• Would it have been appropriate to discontinue the investigation in 2012 when
draft reports were circulated?
• Were material submissions (most notably from the clinical expert) wilfully
omitted from the report?
• Was ‘due process’ followed in compiling evidence for the report?
• Was all relevant material appropriately assessed?
• Did any individuals material to the report have conflicts of interest?
• Have the recommendations within the report been actioned?
• Were communications with Partner B and her advocate effective?
8.1 In October 2009, after the case was referred to The Office of Consumer Affairs, a
review officer recommended that a full incident review should be undertaken, in line with
the ‘Your service, your say’ policy.
8.2 The commissioning and execution of systems analysis investigations are governed
by well-defined structures, policies and processes as noted in Toolkit of documentation to
support the Health Services Executive incident management (2009).
8.3 Initiation of the investigation was suspended, however, after the hospital manager
reported that he had been given legal advice that the incident was sub judice as a result
of an ongoing criminal investigation by An Garda Siochana. This was communicated to
Partner B.
8.4 Notwithstanding the fact that the legal team could not recall offering this advice
(though, it must be noted, the then manager of Hospital X is very clear that it was), the
premise was wrong. The investigation could have proceeded if it did not compromise the
criminal investigation.
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8.5 When we asked if this was now understood by the HSE, the HSE director of primary
care told us:
“We are very clear in our procedures now, in that regardless of whether there is a
police investigation we do our systems analysis.”
8.6 The then manager of Hospital X is, however, less clear, saying:
“That [is], not fully clarified yet as to exactly what can and can’t be done if
something is under investigation by the Gardaí.”
8.7 This point is alluded to in the ‘Your service, your say’ policy which states that
complaints cannot be considered in “a matter that could prejudice an investigation being
undertaken by the Garda Sıochana.” It goes on to say:
“In the instance where complaints fall into [a restricted category], the HSE will
either proceed to investigate the complaint using the appropriate procedures as
outlined in the procedure manual or will inform the complainant of the
appropriate channels through which their complaint should be referred.”
8.8 We have not, however, seen a clear statement in any of the policies and
procedures supplied to us an unambiguous statement that investigations can proceed in
parallel to a criminal process.
Recommendation
R6 If it has not already done so, the HSE should issue clear guidance that
investigations of complaints and serious incidents can proceed in parallel with criminal
investigations.
8.9 The regional director of operations confirmed the commitment to commence a
systems analysis investigation on 11 June 2010. Despite a number of representations from
Partner B’s advocate regarding the perceived ‘inaction’ in initiating the review, Partner B
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and her advocate were not advised of the membership of the review team and the terms
of reference for the investigation until November 2010, some three years after Patient A’s
death.
Comment
The significant period of time – from September 2008 until June 2010 when Partner B
and her advocate met with the regional director of operations – inevitably led
Partner B to believe that her case was not being given the attention that it deserved.
Equally, given the elapsed time of three years after the incident, it made the
subsequent investigation considerably more difficult. After three years, it was to be
expected that individual recollections of detail would be compromised.
Recommendation
R7 As soon as the eligibility of an incident for a systems investigation is established, it
is imperative that a suitable team is identified and that the investigation commences.
8.10 This delay in the initiation of the systems analysis investigation was, inevitably, a
cause of further distress to Partner B and Patient A’s family. It caused them to believe
that the incident was not being treated with the seriousness that it warranted, but also
that it was indicative of ‘the health system’ attempting to ignore or cover up Patient A’s
death.
8.11 A system’s analysis investigation was going on in Hospital X during this period, to a
degree undermining the argument that the necessity to undertake, and ability to
commission, such investigations was not well understood. We were told by the lead NIMT
180 investigator, however, that:
“…parts of the system seem to jump to a system analysis immediately in
appropriate circumstances and parts of the system didn’t, there were certainly
parts of the system where there was not a culture, and there could have been
something quite close beside where there was.”
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And:
“Even within, say, an acute hospital… It wouldn’t surprise me that you have a
culture of not doing it in one place and a culture of doing it somewhere quite
close.”
Finding
F28 As we have argued above, the systems analysis investigation should have been
commissioned immediately after the death of Patient A, and this is now widely
recognised, but we do not believe that this was a result of evasion or any attempt to
‘cover-up’ the circumstances of Patient A’s death. Rather, we find that it was the result
of a series of poor individual decisions taken in an evolving system lacking in the required
degree of understanding and knowledge. We are satisfied that, for the individuals we
have spoken to in writing this report, there is now much greater clarity and understanding,
but clearly cannot comment on the wider health community.
8.12 Establishing the terms of reference for NIMT 180 were subject to the delays in
commissioning the investigation discussed above. While there is a compelling argument
that they could have been finalised while the criminal investigation was being completed,
the belief at the time was that this would not be appropriate.
8.13 The structure of the terms of reference was dictated by the Toolkit of
documentation to support the Health Services Executive incident management. The final
terms of reference follow the template contained within the guidance.
8.14 Partner B and her advocate were consulted on, and had input to, these.
Comment
The fact that Partner B had input to the terms of reference was good practice.
70
Recommendation
R8 The HSE’s Guideline for systems analysis investigation of incidents and complaints,
while never precluding the involvement families and carers of victims of serious incidents,
is not explicit in stating that the views and expectations of these groups should be
considered when writing terms of reference for investigations, and that they should be
supported through the investigation process. The HSE should consider including this in
order to ensure that their concerns are explicitly recognised and addressed.
8.15 In order to address the question as to whether the terms of reference changed over
the course of the investigation, we compared an early draft (from December 2010) to
those that appeared in the final report.
Finding
F29 While there are a small number of minor amendments from the original to final
published version of the terms of reference, we do not believe these to be material.
Comment
In compiling terms of reference, we believe that it is often counterproductive to be
too specific as to what will be investigated. While boundaries need to be set and
specific areas of concern highlighted, the very nature of ‘investigation’ must imply
that there are unknowns which need to be uncovered. Logically, these cannot be
included in terms of reference if they are not yet known.
8.16 The lead investigator was very clear in terms of her remit. She told us:
“The reason there is a standard terms of reference is because it’s supposed to try
to stop people going down an avenue in relation to possible causal factors before
you even start off [the investigation], so the template terms of reference are
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designed to keep investigators very open to any possible systems causes that may
have contributed to a specific incident.”
Finding
F30 We are satisfied that the terms of reference were appropriate, and did not unduly
preclude any line of investigation. We are equally assured that the lead investigator
explicitly understood this.
8.17 On the question as to whether the decision to discharge Patient A was properly
addressed in the report, or if there was any attempt to omit this, we were told by the
lead investigator:
“…we would have been trying not to jump to conclusions before we looked at all
of the data, so we have tried not to jump to conclusions about causal factors when
we received the [Terms of Reference]; but it was certainly emerging as a theme
from the earliest stage of looking at the documentation related to this incident.”
8.18 As to whether there was any attempt to disregard the decision to discharge, she
told us:
“No, because it’s named as a care delivery problem in all drafts.”
8.19 Partner B and her advocate, however, state that the decision to discharge should
have been in the incident description, but that it was not.
8.20 We have seen a draft of the report from November 2011. In this, under care
delivery problems, it states “Decision to transfer the patient from Hospital X to
Community Unit Y.” It does not, however, mention the decision to discharge in the
incident description.
8.21 The HSE’s director of primary care, who in a previous role commissioned the
report, concurred, stating:
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“…the clinical view from [the report clinical expert] was that the patient
shouldn’t have been discharged ... at all that day.”
Finding
F31 We accept, of course, that the terminology changed over the course of the drafting
process, but see no evidence that the decision to discharge was disregarded either through
neglect or design.
8.22 Partner B and her advocate have expressed concerns that the final report did not
answer these terms of reference, specifically in that it, “did not give [Partner B] and
[Patient A’s] family the answers that they sought.”
8.23 Addressing this last point is difficult. It is simply a matter of fact that Partner B
and Patient A’s family did not believe that it furnished them with answers to some
fundamental questions. In our view, however, while this is regrettable, in itself it does
not invalidate the work done.
8.24 The investigation team, as was their explicit task, followed a systems analysis
approach to their investigation. As the name implies, this concentrates more on systemic
responses than individual actions. It is vitally important that serious failures are identified
and investigated in any health system, and undue concentration on individual actions
inevitably reduce the probability of this happening for fear of ‘blame’.
8.25 NIMT 180, we believe, faithfully reports what the investigation team were told by
their interviewees. We confirmed this by reviewing their contemporaneous interview
notes. While Partner B and Patient A’s family (correctly) question the veracity of some of
these statements, we believe that all views were fairly represented – included those
where Partner B’s recollections disagreed with those of other interviewees.
8.26 At a higher level, in the ‘Key findings’ section of the report, ‘Care delivery
problems’– by definition, a recognition that things were not done properly and that this
area was causal to that – were identified in:
• the decision to discharge Patient A;
73
• the administration of oxygen in Hospital X and Community Unit Y; and
• the management of Patient A’s transfer.
And ‘Service Delivery problems’ were identified in:
• the lack of clarity for the need to conduct a ‘robust’ investigation when the
incident occurred; and
• the failure to initiate a systems analysis investigation in October 2009 despite
the ongoing criminal investigation.
8.27 As a result of these identified issues, nine recommendations were made. We are in
full agreement with all of these – both in terms of their substance and style of writing.
8.28 We were surprised not to see a ‘service delivery problem’ in relation to the
execution of the complaint handling by Hospital X. Clearly, in this report we have
interpreted the complaint management in a more negative light than was the case in NIMT
180, but accept that this is a matter of interpretation.
8.29 On the question of whether information was wilfully omitted from the report, we
would simply observe that, in compiling a report with a large scope and multiple inputs, of
necessity a decision that any author has to make is what to exclude from the text. If
every nuance is covered, the document would become too long, with key points likely to
be lost under the weight of evidence.
8.30 The key issue in making the decision as to what to include / exclude is one of
materiality – to what extent does this decision inform learning or recommendations. No
two authors will make the same decisions, nor will any two readers agree in every case
where the material / immaterial boundary lies.
Findings
F32 We are satisfied that the lead investigator in this case always took the decisions to
include or exclude information with the best interests of the final report in mind. Equally,
we are satisfied that the investigation team was not placed under inappropriate pressure
to ignore particular lines of inquiry by any individual associated with the investigation.
We were impressed by the clarity and integrity displayed by the lead investigator in both
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our face to face interactions and subsequent correspondence. We do not say this to imply
that we would always have made the same decisions as the investigation team and report
authors, but we find no grounds to criticise them in their decision-making process.
F33 A natural extension of the finding above is that we do not question whether ‘due
process’ was followed in the production of the report. We found that the lead
investigator was well informed on matters of propriety embedded within the guidance,
and as much as possible followed this. If there was any minor deviation, we are satisfied
that this was inadvertent or predicated on the actions of individual’s peripheral to the
core team.
8.31 A further question raised by Partner B and her advocate is whether key individuals
were conflicted in their roles. Specifically, this was in relation to the lead investigator
and her relationship to the risk advisor, and Regional Director of Operations who at the
time of the incident was Network Manager for the area including Hospital X in the
commissioning of NIMT 180.
8.32 We asked the lead investigator about her relationship with the risk advisor. She
told us:
“We had a networking and learning session for investigators in June 2016, we had
52 investigators from around the country, and [the risk advisor] was there… but I
think I wouldn’t have seen her for at least 18 months before that, or talked to her
on the phone during that time either.”
8.33 She went on to say:
“I’ve never, I think, conducted an investigation within HSE that I’ve not had some
acquaintance with someone, or an awareness of them.”
8.34 When we asked the (then) Hospital Network Manager about any potential conflict
in his role, he said:
“I probably wouldn’t be inclined to accept that, but I could see how [Partner B]
would perceive that in so far as I was part of the system. [I saw] the need for
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obvious reasons for the matter to be dealt with comprehensively, and made every
attempt to satisfy their requirements.”
8.35 With regard the commissioning of this investigation, he said:
“I didn’t have any difficulty with stepping back, and saying, fine, I have taken it as
far as somebody within the system can take it.”
8.36 In a health system the size of Ireland, it is not surprising that individuals are
acquainted with other individuals active in that system. We see nothing untoward in the
relationship between the lead investigator and the risk advisor. This does not appear to
be a personal friendship, but rather a perfectly normal professional relationship.
8.37 In commissioning NIMT 180, the Regional Director of Operations behaved
appropriately for his role at the time. While it is clear that individuals with a direct
personal interest in the case should not be active in its investigation, we believe that he
was sufficiently removed from the incident at that time for this to represent no material
conflict.
8.38 Indeed, an individual with a patient safety responsibility (as the Network Manager)
should actively promote the investigation of serious incidents. It is very common for
Verita to be commissioned by individuals at the head of an organisation or service under
investigation, so we see no difficulty with the Network Manager acting in this capacity.
Finding
F34 We do not believe that the execution of NIMT 180 was compromised by conflicts of
interest. Rather, we believe that all individuals behaved appropriately for people in their
roles in the circumstances that prevailed at those times.
8.39 We were asked by Partner B and her advocate to assess whether the
recommendations made in NIMT 180 have been actioned. Clearly, we did not undertake a
comprehensive review of HSE facilities so cannot comment on actions ‘on the ground’, but
can make the following observations:
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• As stated, we found that the recommendations made in NIMT 180 to be good.
They addressed the identified issues and made specific proposals as to how to
address these issues
• We have seen the action plan developed as a result of NIMT 180, and equally
found this to be good, with specific actions and clear lines of responsibility
toward implementation. We understand, however, that Partner B and her
advocate have not seen this plan.
Recommendation
R9 The action plan resulting from NIMT 180 should be shared with Partner B and her
advocate.
• We have reviewed a number of policies and guidelines developed since Patient
A’s death. We would particularly highlight:
• Administration of oxygen therapy to adult patients policy
• Guidelines on oxygen therapy
• Code of practice for integrated discharge planning
• Standards and recommended practices for healthcare records management
• HSE Incident Management Policy and Procedure / Serious Incident
Management Policy and Procedure
• We believe that all of these policies and guidelines are good. If they are
followed correctly, they will undoubtedly serve to minimise the likelihood of
similar tragic incidents in future
Comment
Patient died and Partner B suffered a loss that no words in a report could ever
alleviate. Partner B was always clear that one of her primary motivations in
pursuing her complaint and demands for an in-depth investigation was to minimise
the likelihood of similar mistakes being made in the future. We fully understand why
Partner B feels that the system has failed her. As we have explored in this report, in
many areas, we agree that the system both failed her Partner on 23 November 2007
and her subsequently. While it might not be immediately apparent to Partner B and
77
Patient A’s family, we believe that a great deal of positive work has gone in to
addressing the failings identified in the care of Patient A. A great deal of credit must
go to Partner B for her strength and tenacity in pursuing her case for such a length of
time. We hope and believe that her efforts have been rewarded by a great legacy for
Patient A – a healthcare system that is safer for future generations of patients.
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Appendix A
Team biographies
Peter Killwick
After graduating from Cambridge University, Peter has worked for 25 years in consulting
covering a variety of strategic and operational issues in a wide range of sectors including
healthcare, automotive, financial services, manufacturing, retail, telecommunications and
government. In Verita, he has extensive experience of complex investigation, project
managing teams and strategy development. He has significant experience of working with
healthcare providers and commissioners and their umbrella bodies both in the UK and
overseas.
Chris Brougham
Chris is one of Verita’s most experienced investigators and has conducted some of its most
high-profile investigations and reviews. As head of training Chris has developed training
courses on how to carry out a systematic incident investigation for serious incidents and
complex complaints. Chris has delivered these courses across a range organisations and
sectors and has consistently received excellent feedback.
Dr John Costello
Dr Costello has been a Consultant Physician in general and respiratory medicine since
1977. He was Head of Respiratory Medicine at King's College Hospital in London for 25
years and first Medical Director of the Trust. He was a Senior Lecturer in Medicine at
Guy's, King's and St. Thomas' School of Medicine and is now a Visiting Fellow.
From 1982 until 1998, he was Director of the Academic Department of Respiratory
Medicine. Dr Costello specialises in Bronchial Asthma and its treatment, including
collaboration with basic scientists in the investigation of mechanisms. He studied at
University College, Dublin, and has since held appointments at a number of hospitals
including Dublin's Mater Hospital, the Royal Postgraduate Medical School, Hammersmith
Hospital, the Royal Brompton Hospital in London, the University of Edinburgh and as
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Assistant Professor of Medicine at the University of California, San Francisco. His other
clinical interests include smoking-related lung disease, lung infections, tuberculosis and
respiratory problems in Intensive Care. He has a medicolegal practice in medical
negligence cases and in pharmaceutical patent litigation.
He was Founder President of the Respiratory Medicine Section at the Royal Society of
Medicine and a Member of Council at the British Thoracic Society. He has published
extensively in peer-reviewed literature on lung disease, in particular asthma, and has
edited and written several books and chapters on the subject.
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Appendix B
Document reviewed
Patient A documents
• Patient A medical records
• Patient A transfer information
• Coroner's record of the verdict Patient A
• NIMT 180 Final report 22.11.13
• Incident report form
HSE policies and Procedures
• Administration of oxygen therapy to adult patients policy
• Guidelines on oxygen therapy
• Healthcare risk management strategy
• Incident reporting policy and procedure
• Disclosure policy
• Code of practice for integrated discharge planning
• Management of consumer feedback policy and procedure
• Standards and recommended practices for healthcare records management
• Toolkit of documentation to support incidents
• Transport of the critically ill
• Guideline for the systems analysis investigation of incidents
• Incident management policy and procedure
• Guideline for the systems analysis investigation of incidents and complaints
• Safety incident management policy
• Serious incident management policy and procedure
• Your service, your say - management of consumer feedback
• Admission policy of the outreach palliative care support beds
Other documents
• HSE investigation transcripts
• Correspondence between Partner B and Hospital X
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• Correspondence between Partner B and HSE
• Scheduled of unanswered questions/maters unaddressed
• NIMT 180 agenda and minutes
• Review application to the information commissioner and report
• Submissions from Partner B, Practitioner 1 and Practitioner 2
Note – In total, Verita received over 300 documents and very extensive correspondence
relating to this case – too many to individually list here. Instead, we simply highlight
those of particular interest.
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Appendix C
Partner B’s questions
Below is shown the full list of questions provided to the Verita investigation team by
Partner B and her advocate.
Event/Incident:
• Why did the [Medical Practioner 2] discharge [Patient A] when he was clearly medically unfit?
• Knowing [Patient A] was in end-stage respiratory failure & the fatal consequences for his patient if his 02 supply was not ensured....WHY did he not ensure it?
• Why did the [Medical Practioner 2] discharge [Patient A] to a place ([Community Unit Y]) that never at any time had the capacity to provide for his oxygen needs?
• Why did the [Medical Practioner 2] not ensure that a prior check was done re the capacity of [Community Unit Y] to provide the high-dose oxygen on which [Patient A’s] life depended?
• Did the [Medical Practioner 2] check with [Community Unit Y] or the [Medical Practioner 1] regarding the oxygen supply available prior to making the decision to discharge?
• If a prior check was not done on oxygen capacity at [Community Unit Y] in order to establish if it could or could not provide continuity of [Patient A’s] oxygen supply, then WHY NOT?
• What was the precise role of the [Medical Practioner 1] in the discharge arrangements?
• Who is the person responsible for the Discharge of [Patient A]?
• Why was [Patient A’s] Respiratory Physician not consulted about his condition or his oxygen requirements prior to his discharge?
• Having made the decision to discharge [Patient A], why did the [Medical Practioner 2] if he believed [Community Unit Y] had the necessary facilities not ensure appropriate transport arrangements with nurse/medical escort for his terminally ill patient whom he had decided to send 27 miles away from the hospital?
• The discharging [Medical Practioner 2] we understand is responsible for ensuring continuity of his patient’s care and ensuring that the receiving facility can meet his patient’s needs. Can and/or did the [Medical Practioner 2] delegate this responsibility to someone else?
• If so, to whom?
• What discussions took place within [Hospital X] prior to the decision to discharge [Patient A]?
• Who was present at these discussions? The [Medical Practioner 2] physician stated in a written submission to the Medical Council that the Ward Sister was with him and his team on that day so what was the Ward sister’s role/function/responsibility in this continuous catalogue of failures and omissions?
• Where was the ward CNM when everything being done and not being done was ensuring an adverse outcome for a helpless and wretchedly distressed patient?
• Who was responsible for ensuring the patient’s safety in the transfer process?
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• Why was nothing done to ensure [Patient A’s] safety?
• Why were only those things done, and omitted to be done, that would, and did jeopardise his safety and ensure an adverse outcome?
• This was not a case of “things going unexpectedly wrong”. “Things” were never right. Every arrangement was wrong from the beginning and exposed [Patient A] to obvious and foreseeable danger. Why/How was this allowed to happen?
• Who made the arrangements for the transfer?
• Who booked the Ambulance?
• How did ward or medical staff manage to categorise the patient’s transfer status as AS3? Who is responsible for determining the transfer status of a patient?
• Who rang [Community Unit Y] at 10.28a.m.?
• The Risk Advisor claimed to know what the [Hospital X] caller said in the 10.28a.m. phone-call. Everyone else, including NIMT claimed they did not know who the caller was. Why was the Risk Advisor not asked to either (a) identify the caller, or (b) admit that she had fabricated her version of the call?
• If she had fabricated her version of the call why did it support the [Medical Practioner 2’s] claims in his Jan response re 02 (which she had contradicted in her Jan report) for which there was no prescription, and contradict the claims in my written complaint for which there was a prescription?
• Why did the Risk Advisor claim to know that the need for 60% Oxygen or 12-15L/min. was not mentioned in the phone call to [Community Unit Y] when there was a prescription for it, and that the need for 6L/min 02 was ‘mentioned’ when there was no prescription for it?
• Who deemed [Patient A’s] care and safety worthy of only one 67 second telephone call to [Community Unit Y] staff during which, according to the Risk Advisor’s version of the call the wrong information about the patient’s oxygen requirement was given? (More questions about this phone call below under ‘HSE Response’)
• Why was [Patient A] discharged in the absence of the results from the full blood count and Arterial Blood Gas tests carried out that morning?
• Why were the ABG results not transmitted to [Community Unit Y], which could have been done nearly 1 hour before [Patient A’s] arrival there? If they had been transmitted could this have averted the whole disaster?
• Why did [Hospital X] ward CNM not give a nurse-to-nurse handover to [Community Unit Y] CNM as we understand is standard procedure in transfers of this kind, or arrange that another nurse would do so?
• Why did those responsible for [Patient A’s] care allow this to happen, i.e. NO precheck of [Community Unit Y] oxygen capacity, NO ensuring continuity of [Patient A’s] 02 supply, NO appropriate transport arrangements for a terminally ill patient, NO nurse-to-nurse handover, NO transmission of information re [Patient A’s] condition, his nursing care requirements or his oxygen requirements and one mere 67 seconds call to [Community Unit Y] re [Patient A’s] proposed transfer?
• Why were the paramedics allowed to remove [Patient A] from the ward without a handover? The Clinical Expert at one of our meetings commented to [Partner B] about this, “they (i.e. the ambulance crew) just came into the ward and took him!” To which [Partner B] said – “as if he were just a bag of coal?” [Clinical Expert] responded – “Yes! Well NO, actually there would have been more formality about a bag of coal…they’d have had to sign for it.”
• Did the Ambulance staff receive any information and/or instructions about [Patient A’s] condition prior to their arrival at the Hospital, other than that received from Ambulance Control, i.e. that this was an AS3 transfer ?
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• Why did ambulance paramedics not query the AS3 status when they arrived into the ward? Or did they? Or, given the ‘pecking order’ among medical staff is paramedic questioning of decisions by [Medical Practioner 2]s and medical staff accepted? The Chief Ambulance Officer’s response of 10th Jan’08 appears to have been treated by the Risk Advisor and Hospital Manager as of no significance despite its calling into serious question aspects of the [Medical Practioner 2’s] response of 9th Jan’08 re [Patient A’s] oxygen. The Ambulance Officer’s response accorded with information in medical records and the [Medical Practioner 2’s] did not - yet the discrepancy was not addressed?
• Are Ambulance paramedics not allowed to query the AS3 status when they realised that proceeding with the collection of another patient would, and did result in leaving the terminally ill [Patient A] waiting for nearly 1 hour in the fully open ambulance exposed to the cold on 15L/min 02, WCC 19.6, P(02) 4.76. WHY was this allowed to happen?
• Who was or should have been responsible for patient handover at the various points?
• Why were there no handovers?
• Why did [Community Unit Y] staff not adhere to standard procedure in transfers of this kind and insist on getting a nurse-to-nurse handover of the patient when none was forthcoming from [Hospital X]?
• Was it irresponsible and professionally inappropriate of [Community Unit Y] staff to accept the care of a patient about whom they knew nothing, i.e. had not received a nurse-to-nurse handover of him, knew nothing about his condition, his nursing care or oxygen requirements and did not know the limitations of their own oxygen equipment or the necessity for having a back-up 02 cylinder in the room?
• Why did they not ask the paramedics for a handover?
• Why were [Community Unit Y] staff so fatally ignorant about their own oxygen equipment and its capacity?
• Why did they not have a back-up oxygen cylinder in the room that had allegedly been prepared by [Community Unit Y] CNM for [Patient A] in end-stage respiratory failure? (BOC Gases had advised [Partner B] and [Patient A] that there should always be a back-up cylinder in case of power failure, accidental unplugging, equipment malfunction)
• Why did [Community Unit Y] staff not heed the paramedic’s warning that [Patient A] was on 15L/min? Could a patient be in a worse situation than this, knowing what he knew about concentrators and his need for 15L/min 02..at the mercy of staff who did not know these things? - his final minutes of life engaged in a life-and-death struggle as previously outlined on pg 2.
• Why did they ignore [Patient A’s] cries that the oxygen flow was insufficient?
• Why did they allow the paramedics to leave despite [Patient A’s] obvious distress and the paramedics’ warnings? and then, some 15 minutes later but too late, call for the ambulance to return to [Community Unit Y] because there was ‘a problem with the oxygen’?
• Why did they not shout STOP, instruct the paramedics to remain and make immediate contact with [Hospital X]?
• Why did no one SHOUT STOP at any stage in this appalling litany of reckless indifference to the care and safety of a helpless, terminally-ill patient?
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HSE Response: [Community Unit Y] and Complaint 2007/8
There was no acknowledgement of an Adverse Incident having happened by the HSE
at any level at that time despite it having been witnessed by HSE frontline staff in
[Community Unit Y] on 23rd Nov 2007. When shortly after [Patient A’s] funeral I
rang [Hospital X] to establish the circumstances surrounding [Patient A’s] discharge
and transfer I was advised by D o N or Nurse Manager to put my concerns/questions
in writing to the Hospital Manager which I did.
• Why did staff at [Community Unit Y] not follow the HSE Mid West Risk Management Policy?
• When was an Incident Report form actually completed at [Community Unit Y] and by whom? NIMT claimed in 2 draft reports that it was not completed until Jan 2008, and then claimed in their final report that it was completed on the evening of [Patient A’s] death, 23rd Nov 2007? Which, if either, is the truth?
• Who in the local HSE Management Structure were informed of the details of the event and when?
• Why did HSE Community Services not initiate a Systems Analysis Review?
• Were the relevant Community Services Management made aware of this event?
• If so who and by whom?
• Why did the [Community Unit Y] Director of Nursing allegedly keep this incident report form for 6 weeks approx, before forwarding it to the [Hospital X] Risk Advisor? The NIMT stated that the DoN was going over the incident with the staff involved?
• 6 weeks spent ‘going over the incident with the staff involved’ could be deemed to be coaching the staff involved re answering questions. Was that happening? (See below NIMT Review re their responses).
• We were also told that the DON informed or discussed the event with the Risk Advisor days following the event – Where is the truth?
• When was the Risk Advisor notified of the events of 23rd November 2007?
• What did the Risk Advisor do when she was made aware of the events?
• What did the Risk Advisor do with the Incident Report form when she allegedly received it given that she was already assisting with the complaint response at the time?
• Did the Incident Form when completed accurately reflect what happened on 23rd November 2007?
• Why, within days of [Patient A’s] death, did [Community Unit Y] staff order BOC, to remove the concentrator in use that day? (A fact not acknowledged or addressed in HSE responses of Feb 2008 or Nov 2013.) BOC told [Partner B] that it was at least 12 years old.
• Why did [Community Unit Y] staff not preserve the scene for a preliminary examination as recommended in such an event?
• What was the Coroner told that allowed the death to be certified given that the circumstances of [Patient A’s] death in our view made it a notifiable death and allowed the Coroner no discretion?
• Was the Coroner informed of the circumstances of [Patient A’s] death, the discharge and transfer etc?
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• Why, given the circumstances of [Patient A’s] death, were the Gardai not notified?
• Did the Hospital make any contact with Community Services Management following the event and particularly following the receipt of the written complaint in December 2007?
• If they did what did they do about it?
• Why was a copy of the original complaint not forwarded to the Community Services with responsibility for [Community Unit Y]?
• If it was, what was their decision and/or instructions to staff?
• Who decided how the complaint would be dealt with?
• Did any person see that this was not a complaint to be dealt with under the HSE’s complaints policy given the circumstances of what happened that gave rise to and were outlined in the complaint?
• Was it appropriate that management of the written complaint and questioning of the [Medical Practioner 2] were left to a Staff Officer?
• Was she receiving advice/direction from anyone more senior? If so who?
• Why did she continually ask the wrong questions and never once ask the right questions?
• Were any Senior Managers in HSE Mid West informed of the incident and/or the complaint i.e. Local Health Manager, Hospital Network Manager, Regional Risk Manager? These managers had responsibility for patient safety in their respective areas and would have been expected to liaise together on important issues.
• Why did the Hospital Manager or at least the Risk Advisor not initiate a Systems Analysis Review in this case, as they had done in the A.M. case at the same time? (see Related Background Information)
• Did the Risk Advisor and/or the Hospital Manager suggest a system’s analysis?
• Was he/she/they stopped from carrying one out and if so by whom?
• Their systems analysis of the A.M. case was underway at the time of this incident and receipt of the written complaint. Were they ‘put off’ doing a systems analysis in this case by senior management in an attempted ‘damage limitation’ exercise? The A.M. case had gone public; [Partner B] and the family had not gone public.
• By not carrying out a systems analysis who or what were they trying to protect? – The [Medical Practioner 2], the Hospital or the HSE or all??
• Why did the Risk Advisor withhold from her 21st Feb’08 report that part of her 23rd Jan’08 report which had shown her full knowledge (a) that the [Medical Practioner 2’s] response of 9th Jan’08 did not accord with information in the medical records, (b) that, contrary to the [Medical Practioner 2’s] claims re 4-6 litres 02, [Patient A] had needed 15L/min 02 and had been discharged to a place that could only provide 5L/min, (c) that the result of this was, (quoted from her Jan report) “Therefore, 02 available to the patient on arrival at [Community Unit Y] was inadequate. Pt could only receive 20-21% at maximum flow-rate of 5 litres,” and (d) that the family’s complaint was completely valid.
• Why was this crucially relevant information withheld from her 21st Feb report, which was then copied almost word for word and used as the official response to the family’s complaint when what was centrally relevant to their complaint had been withheld from it? and WHY did HSE then insert into its official response material that was not factually accurate and not clinically correct and which did not accord with information in the medical records?
• This question has never been acknowledged or addressed in a HSE response, despite [Partner B] raising this issue repeatedly, especially with the NIMT Review Team and the Commissioner of the NIMT Review.
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• Why did the Hospital Manager use the Risk Advisor’s 21st Feb’08 report as his official response to the family’s complaint when (a) it had been written 8 days before the final response was received from the responsible [Medical Practioner 2], on 29th Feb’08 and (b) the [Medical Practioner 2’s] inaccurate claims in his final response (and in his first response on 9th Jan’08 in the possession of the Risk Advisor) were not addressed, had not been referred for senior clinical opinion and were now, like the centrally relevant information in previous bullet, withheld from the HSE’s official complaint response which purported to the family to be the result of a 3 month investigation? Why did this happen?
• Was it the Hospital Manager’s decision alone? If so, why did NIMT not question him about it?
• Was it made after consultation with more senior management?
• Was the report from the Chief Ambulance officer considered by the Hospital Manager? The Chief Ambulance Officer’s report (Received 10/1/08) completely contradicted the [Medical Practioner 2’s] version of the Oxygen needs (Received 9/1/08)
• Was the nurse who signed the medical records as having completed the patient’s discharge, arranged transport and notified the carer questioned prior to the complaint response issuing and as part of the alleged ‘investigation’ given the catastrophic consequences of both the transport arrangements and non-notification of the carer? We presume that ‘the carer’ referred to [Community Unit Y].
• Was the same Nurse questioned about her retrospective and inaccurate entry in the records (i.e. that [Patient A] was on 6 litres prior to discharge and discharged with 6 litres in situ) for the ‘investigation’, considering that this was the only back-up in the records for the [Medical Practioner 2’s] claims in his 9th Jan’08? The [Medical Practioner 2] later used this nurse’s retrospective entry to try to justify yet another of his questionable claims in his Inquest deposition (July 2009) that on transfer [Patient A] was on 6 Litres. He was caught out under cross-examination at the Inquest when [Partner B’s] solicitor confronted him with the discharge prescription for 60% 02. His incoherent denial of knowing anything about it could not be reconciled with the hospital permanent prescription for 60% 02 which he had authorised for [Patient A]. [Partner B’s] appeal to the Information Commissioner re this nurse’s retrospective entry was upheld.
• Were other key people involved in [Patient A’s] care asked to respond to the complaint? e.g. the on-call doctor who had been ‘asked to see’ [Patient A] on the night before he was discharged and had instructed that 15L/min 02 be continued. The junior doctor obviously, in our view, had not been asked to respond since she’d have pointed to her discharge prescription, and the nurse who completed the discharge, arranged transport and allegedly notified carer has apparently been allowed off the hook having claimed that she filled in this form retrospectively and made her untruthful entry in the records retrospectively, so that’s alright then, Is it?
• Did the Hospital Manager and the Risk Advisor use this nurse’s untruthful retrospective entry in the records to support their own decision to cover-up for the [Medical Practioner 2] and go along with his version of events despite knowing that his claims, and those of the nurse, conflicted with information in the medical records? [Partner B] knew that the nurse’s retrospective entry was inaccurate. She was present with [Patient A] prior to discharge and he had asked that the oxygen be increased. The attending nurse did so when it was brought to her attention by [Partner B]. Also when the Paramedics arrived to remove [Patient A] from the ward at 1pm they put him on 14L/min.
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• Did the Hospital Manager not examine or consider seeking external clinical assistance to adjudicate on the [Medical Practioner 2’s] many versions of events or was the [Medical Practioner 2] only reporting to the Network Manager?
• Why did the HSE at National level further prolong the process when they were contacted in 2009 following the inquest?
• Why did the HSE at National Level given the circumstances outlined to them regarding the lack of an appropriate investigation, begin a process of passing the correspondence from Risk to Consumer Affairs and back again which forced us to deal with the Regional Director of Operations in HSE West who previously had been the HSE Mid West Hospital Network Manager?
• Did this happen because Risk & Consumer Affairs knew that the RDO in his previous capacity as Network Manager had been involved in this case and that this ‘hot potato’ should end up in his lap?
• Were they making the decisions on their own or were they been advised by anyone else?
NIMT Review
• Given the failure of the local HSE Response it was hoped, given its terms of reference, that the NIMT Review which commenced in Dec 2010 would eventually give [Partner B] and [Patient A’s] family the answers they sought. Why did the NIMT Review fail to do so?
• Why did the NIMT Review fail to deliver as per its Terms of Reference?
• Why did the NIMT Review fail to address the issues above regarding the HSE Mid West 2008 response given its terms of reference?
• We had issues with the HSE’s NIMT Review’s from the time of its first Draft Report in March 2012. This draft alarmed [Partner B] and her advocate for many reasons e.g. (1) a view that the initial HSE response of 29th Feb’08 was in accordance with HSE’s Complaint Management Policy and (2) the omission from their incident description of the decision to discharge the patient. This omission was in defiance of the independent clinical expert to the NIMT Review team who, in the presence of [Partner B] and her advocate, stated that the decision to discharge had been disastrous and should never have happened as the patient was far, far too ill. There were many other reasons in the first draft report of March 2012 for [Partner B’s] and her advocate’s alarm but (1) & (2) above were particularly disturbing, in their view, for the following reason:- The NIMT Review 2011-2013 undertook in Dec 2010 to examine the HSE’s initial response Dec’07-Feb’08 which, in addition to the serious issues already outlined had never acknowledged that this incident involved ‘clinical judgement’ and had very determinedly refused, in breach of HSE’s Complaint Management Policy, to appropriately investigate it. Instead of addressing this failing of the initial HSE 2008 response the NIMT Review Team was now, in 2012, factoring out the ‘clinical judgement’ element from their own incident description, i.e. the decision to discharge, and reducing the incident to ‘the transfer of the patient’ only. In view of these and other concerns we asked at that time in 2012 that the team be disbanded. The HSE through the Commissioner of the Review failed to agree and insisted that the review continue. We subsequently asked the Director General of the HSE and the Minister for Health to intervene and stop this review given the way it was being conducted, but without success. Why were we not listened to?
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• Why did the NIMT Review Team persist for so long in attempting to omit the decision to discharge from their incident description, thus attempting to limit the incident to ‘the transfer of the patient’? Some of the first things [respiratory expert] unequivocally stated to [Partner B], in the presence of her advocate and the other two reviewers in May 2011were - “[Patient A] should never have been discharged from the hospital, he was far, far too ill, the decision to discharge him was disastrous and the [Medical Practioner 2] and medical team should be held to account for it.” Despite this, the Review team persisted in omitting ‘the decision to discharge’ from their incident description, and tried to limit the incident to ‘the transfer’ of Patient A. At a meeting with the Review team and the Commissioner in July 2013, i.e. more than 2 years later, [Partner B] challenged them, among other things, about their incorrect incident description in their Final Draft report. They again resisted strongly. [Clinical Expert] intervened, voicing his agreement with [Partner B] that their incident description was wrong. Why was this not addressed earlier?
• Why then does their Final Report make a somewhat incoherent statement (on pg3) that ‘The incident in relation to the discharge and transfer of the patient....relates to the transfer of the patient...’. This is only one of many incoherent statements in the report that should have been addressed prior to its finalisation. The Review has not addressed either WHY or HOW this decision was made, See Pg 4 & 32 of their Final Report.
• Who made the decision to exclude some of those and other comments made by [Clinical Expert] which would be vital to the family and to the learning from this case?
• Why were statements he made at our meetings in July 2013 in which he was particularly forthright concerning the volume of oxygen and the various discrepancies in the draft review and the records concerning same apparently ignored to a large degree?
• Why was [Clinical Expert]’s contradictory comment at a meeting with us in July 2013 concerning one particular footnote with which he took issue relating to Oxygen i.e. the number of litres/min required to deliver 60% not addressed in the final report as we requested?
• Why did the NIMT state in their Final Report that an Incident Report Form had been completed in [Community Unit Y] on the night of the incident (23rd Nov’07) when they had previously told us in their 2012 & 2013 draft reports that the incident report form had been not been completed until Jan 2008? What is the explanation for this radical change? Why did this change occur prior to the final report issuing?
• The NIMT Review Team claimed to have been unable to identify the nurse who made the 67 seconds call to [Community Unit Y], as did the Hospital manager and the Director of Nursing which is strange given that 1: the Medical Records identify a Nurse as having completed the discharge, arranged transport and notified the carer but apparently has been let off the hook after claiming that she filled in this form retrospectively, and 2: the Risk Advisor first mentioned the call in her report of January 2008 – so she either (1) knows the identity of the caller, or (2) fabricated her version of this call. Why has an explanation not been provided to date?
• Why did the Review team not adequately investigate the obvious discrepancies/inconsistencies in the Medical Records as pointed out to them by [Partner B] and eventually borne out by the Information Commissioner’s decision of Oct 2014? (Copy of decision attached)
• Why is there no detail in the review of the different grades of staff interviewed by the Review Team?
• Were all interviews face to face interviews? If not why not?
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• Was the role of the Local Area Health Manager and the Hospital Network Manager examined by the NIMT review team? If not why not given the terms of reference for the review? These managers had responsibility for patient safety in their respective areas and would have been expected to liaise together on important issues such as this adverse event.
• Did the Review team examine the role played in the management of the response to this adverse event by the various other Senior Managers within HSE both locally and nationally?
• Did the Review Team interview [HSE Executive] as to how he fulfilled his patient safety role as Hospital Network Manager in this case?
• Did the Review Team or the HSE at a higher level not consider the fact that there may have been a potential conflict of interest in this case for [HSE Executive]?
• Was the response to the incident by staff in [Community Unit Y] examined by the review team and if so why is there no comment on this in the report? As the site where the event occurred it is our view that they should have initiated the review/investigation process at a local level. These same staff apparently did not preserve the scene for a preliminary examination as recommended in such an event.
• How could the Review Team form a view that there was a lack of clarity regarding the need for a robust investigation in this case given the circumstances outlined earlier regards the AM case and the fact that the Staff Officer sought the assistance of the Risk Advisor in dealing with the initial written complaint? Surely this was a case of a failure to carry out a review not because of lack of clarity but for some other unknown reason?
• Why did NIMT make such an untruthful claim, if they had addressed or investigated any single aspect of the HSE’s original response in the first place?
• Why did the Review Team apparently ignore the fact of the concurrent incident reviews being carried out that were public knowledge?
• Did the Review Team ask the Hospital Manager for his response to the Risk Advisor’s 23rd Jan ’08 report which unequivocally contradicted the [Medical Practioner 2’s] version of events in his 9th Jan ’08 response?
• Why did the Review Team not address the Hospital Manager’s very questionable decision not to escalate this complaint for senior clinical opinion after receiving the Risk Advisor’s report of 23rd Jan ’08, and his apparent approval of withholding that part of her report that was pertinent to and centrally relevant to it? The Risk Advisor’s clinical comments in her January report which were in accordance with the clinical information in the medical records but in conflict with the [Medical Practioner 2’s] version of events was, in the main, omitted from her February report and from the complaint response - Why?
• Did the Review Team question the Risk Advisor regarding the serious differences between her Jan and Feb reports?
• Was this issue even pursued by the Review Team? [Partner B] raised this issue twice at meetings in July 2013 with the review team and the Commissioner and it still was not addressed in the review.
• Was the report from the Chief Ambulance officer to the Hospital Manager (following his consideration of family’s complaint) considered by the NIMT Review Team? There is no indication from the review report that it was.
• Were any other responses to Hospital management relating to [Partner B’s] original complaint examined by the NIMT review team?
• Were other key people involved in [Patient A’s] care interviewed by the NIMT review team? e.g. the junior doctor who wrote the discharge documentation and the nurse who completed the discharge, arranged transport and allegedly
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notified carer, or the on-call doctor who had been ‘asked to see’ [Patient A] on the night before he was discharged and had instructed that 15L/min 02 be continued.
• Did the Review Team examine the role played by the [Medical Practitioner 1] in the Discharge process and its impact on decisions made?
• We became aware post the NIMT Review that the [Medical Practitioner 1] had responded twice to the Review Team regards draft reports. In one he emailed the Review Team but in the second he emailed [Individual] who worked in the Office of the Commissioner of the Review – How were the Review Team conducting their business? Surely the Commissioner’s office should not have been involved in receiving and/or circulating documents etc.? How much more of the NIMT Review was passing through his office? Was this appropriate especially in view of his previous involvement in the response to this event?
• How did the NIMT team ensure security and confidentiality of documents/evidence etc?
• How could a Senior NIMT person relate to my advocate a personal view given by me to the Review Team at a private meeting?
• Did the NIMT Review Team examine the reason why and/or on whose instructions a nurse made a retrospective entry in the records that [Patient A] was on 6L/min prior to discharge with Sats 80% - 86% and was discharged with 6Litres in situ, which just happened to support the [Medical Practioner 2’s] version of events but which, like the [Medical Practioner 2’s] response, conflicted with information in medical records and which was inaccurate as [Partner B] was present with [Patient A] prior to discharge and he had asked that the oxygen be increased. The nurse did so when it was brought to her attention by [Partner B] – Also when the Paramedics arrived to remove [Patient A] from the ward at 1pm they put him on 14L/min
• Was this retrospective and untruthful entry in the records (i.e. that [Patient A] was on 6 litres prior to discharge and discharged with 6 litres in situ) questioned or investigated by the NIMT Review Team, considering that the [Medical Practioner 2] could not have expected to be believed with the claims in his 9th Jan’08 response that [Patient A] only needed 4-6litres 02 without some back-up for what we view as his outrageous untruth in the medical records? The previous entry in the Medical Records detailed Sats down to 68% the night before, the on-call doctor being ‘asked to see’ [Patient A] and ordering 02 increased to 15L/min and to continue this treatment and, as confirmed by [Clinical Expert], Sats on the morning of discharge were 76% on 15L/min. This nurse’s retrospective entry in the records provided the back-up and the [Medical Practioner 2] later used this nurse’s retrospective entry to try to justify yet another of his untruthful claims in his Inquest deposition (July 2009) that on transfer [Patient A] was on 6 Litres. His inaccurate and untruthful claim was exposed under cross-examination at the Inquest when [Partner B’s] solicitor confronted him with the discharge prescription for 60% 02. His babbled incoherent denial of knowing anything about it was impossible to reconcile with the hospital permanent prescription which had been authorised by him for [Patient A] as 60% 02. [Partner B’s] appeal to the Information Commissioner re this retrospective entry was upheld.
• There appears to be a suggestion in the NIMT Review that this nurse’s signing as having completed the discharge, arranged transport, notified the carer etc was also retrospective. This was used by the NIMT Review Team to explain why her responses to their questioning of her were not in their report, but without acknowledging that this implied if true that nobody had completed the patient’s discharge?
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• Did the NIMT Review Team examine and adjudicate on the [Medical Practioner 2’s] many versions of events to various personnel and bodies? - See Pg 43/44 of NIMT review for a further version to those previously furnished. It is our view that the Review Team should have had [Clinical Expert] in attendance at the interview with the [Medical Practioner 2] in this regard. Why was he not?
• Why did the NIMT Review Team give credence to the [Medical Practioner 2’s] claim that [Partner B] insisted on [Patient A’s] discharge when so convincing was the evidence against the veracity of this entry by the [Medical Practioner 2] that the Information Commissioner has decreed that a note re its unreliability be inserted in the medical records? [Partner B] can also confirm that, contrary to the [Medical Practioner 2’s] entry in the records [Patient A] was not at all happy about being moved to [Community Unit Y] and, as is evident in the medical records and in the observations of [Clinical Expert] that [Patient A] was not ‘feeling better’.
• Why did the NIMT Review Team not examine and adjudicate on the fact that the HSE at National level further prolonged the process when they were contacted in 2009?
• Was there a prior decision by the HSE at National level to not conduct an appropriate review of this case given a comment at one stage by a Senior Member of the NIMT to the effect – “Why should we bother... you are going to the Ombudsman anyway.”
• Did the NIMT reviewers’ personal and professional acquaintance with the Risk Advisor unduly influence their review?
• Why did the Commissioner of the Review not disband the Review Team once concerns were brought to his attention in April 2012?
• Did the NIMT Review Team not consider the actions of staff that discharged a medically unfit man to a certain death worthy of notification to the Commissioner?
• Or did they? And if so what action was taken by the Commissioner?
• Given the catastrophic consequences of both the transport arrangements and non-notification of the carer were the actions of the nurse who signed the medical records as having completed the patient’s discharge, arranged transport and notified the carer notified to the Commissioner? Also should he have been notified of the retrospective and inaccurate entry in the records that [Patient A] was on 6 L/min prior to discharge & discharged with 6 Litres in situ?
• Why was [Clinical Expert] not asked to attend interviews with Medical Practitioners?
• Did the NIMT Review Team examine the findings and recommendations of the Inquest?
• Did the NIMT Review Team look at the Inquest Depositions of the various personnel and reconcile those with the records and other evidence available?
• Why could the NIMT review team not produce a report that was credible and without the obvious contradictions and anomalies therein? The chronology in the review alone is not in our view an accurate and reliable chronology.
• Why did the NIMT Review team appear to ignore all the evidence pointing to the questionable nature of the [Medical Practioner 2’s] version of events? This same evidence was deemed sufficient by the Information Commissioner in his decision of Sept 2014 to add amendments to the [Medical Practioner 2’s] entry in the medical records.
• Was an action plan prepared as required according to the terms of reference?
• If not why not?
• If prepared where is the Action Plan?
• If prepared - Why was a copy not sent to [Partner B] and her advocate?
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• Why did the HSE attempt to change this part of the terms of reference without prior consultation with [Partner B] and her advocate?
• Why did the HSE at the highest level take so long to accept and acknowledge our concerns regarding the NIMT Report?
• How many more potential [Patient A]’s are out there as a result of the inadequate handling of this case by the HSE at so many levels?
• And, finally, why did the Review team not ask the question – Why did no one at some stage shout – Stop?