By Niall Hunter - Editor
The review of deaths at Leas Cross expresses particular concern at the short period between transfer from another hospital and deaths of patients investigated in the report.
Prof Des O'Neill, in his report, says that in a previous Irish study of deaths following transfer to nursing homes, the average duration of survival was 17 to 44 months.
In Leas Cross, the average time of death among those investigated between 2002 and 2005 was 7.3 months among transfers from all hospitals, but only 2.5 months in transfers from St Ita's Psychiatric Hospital in north Dublin.
"This was a particular cause of concern and mirrors concerns expressed in strong terms by consultant psychiatrists in St Ita's Hospital to both the NAHB (the governing health authority at the time) and the Director of St Ita's Hospital."
In Leas Cross, it was found, there was a steady rise in one-year mortality from 1998 to 2000, and thereafter it remained steady at 38% to 39%.
The report notes that there is an almost complete absence of systematic monitoring of deaths in Irish nursing homes.
It says despite the existence of a statutory obligation to report nursing home deaths to health authorities, in Leas Cross only 31 of 60 notifiable deaths were notified to the health board for the period reviewed.
"While the health board was concerned that deaths of residents in hospital were not being reported, legal advice to the health board at this time indicated that the nursing home was not obliged to report deaths of residents who died in hospital."
The report says a significant number of other nursing homes in north Dublin did not fulfil their statutory obligation to report deaths, with 33 unreported deaths in eight other nursing homes in 2004 and to June 2005. The HSE has since written to all nursing homes reminding them of this statutory obligation.
The report also notes that not all deaths in Leas Cross were referred to a coroner, even after a recommendation from the local health board that all such deaths be reported to the coroner.
The O'Neill report points to only 10% of the patients in the review having their weight recorded on admission; this is important in terms of dealing with malnutrition, is a marker of the standard of nursing care and is required by regulations.
Similarly, it notes that only 14% had their skin condition recorded on admission; this is important in terms of preventing the very serious condition of pressure sores (which if inadequately managed can lead to death), and a failure to record skin condition is also a marker of the standard of nursing care.
The report expresses grave concerns about pressure sore management at Leas Cross. It notes that inadequate documentation and lack of clear care routines for these sores are notable in one of the Leas Cross cases that entered the public domain. In that case the coroner entered a verdict of death by medical misadventure.
On restraints, the report says an alarming number of the Leas Cross residents were noted as being nursed in Buxton Chairs, and although there was a written policy on restraints, there is only evidence of one relatively cursory attempt at surveying restraints and consent.
The report says documentation supplied for the review gives no sense of the application of an informed policy on restraints, which reflects the reality that restraints impose a very great hazard to frail older people in nursing homes.
Medical cover was almost exclusively provided by a single medical officer at any one time at Leas Cross. The case in the public domain through the Coroner's court raised serious issues over the role of the medical practitioner in pressure sore cases, and in only a very small number of the 33 cases with pressure sores was there a medical note observing the sores.
The report says in two instances the nursing notes mention difficulty in contacting a doctor, in one case extending for three days. There was no evidence of a policy on dysphagia (difficulty swallowing), although a significant minority of those who died in Beaumont Hospital (after transfer from Leas Cross) were detected as having this significant disorder.
The report says the nursing qualifications and staffing at Leas Cross were clearly deficient in terms of specialist expertise, nursing numbers and nursing infrastructure.
"This is perhaps the single most grievous area of concern of practice within the nursing home."
It says there is no documentary evidence that the proprietor of Leas Cross sought senior staff with experience of specialist nursing of older people.
The review looked at the A&E records of 46 of the patients who died in Beaumont Hospital following transfer from Leas Cross. Twenty of these patients who died had renal failure, often at elevated levels, for which dehydration was likely to be a contributory factor, particularly given the routine lack of fluid charts in Leas Cross, the report noted.
Pressure sores were noted in 12 patients, and six patients had swallow disorders.
The O'Neill report notes that an independent inspection report on the closure of Leas Cross (it closed in 2005), commissioned by the proprietor, concluded that the majority of residents pointed out they had no complaints with the home's standards of care and were all very happy.
Prof O'Neill says this is not backed up by a clarification of methodology or of any data. He says an accompanying report by a UK doctor refers to the 'dumping' of pre-terminal and terminal patients at Leas Cross as if there was no sense of the nursing home having a contract with the HSE or insight into their professional responsibilities.
The Department of Health, in addition to health service staff, responded to Prof O'Neill's findings. Some of the responses disagreed with aspects of his findings, one former health board official claiming them to be 'biased and inaccurate'. Another response from a senior health official claimed Prof O'Neill had gone beyond his terms of reference, and responses also referred to a lack of resources to uphold high standards of care.
The Department of Health disagreed with Prof O'Neill's contention that it had failed to address the needs of old people. It said it is planning legislation to put a social services inspectorate on a statutory basis.
However, Prof O'Neill points out that the Department first mooted this 13 years ago.
The most telling statement, however, is that which opens the response of the former CEO of the Northern Area Health Board, whose senior management had ultimate responsibility for overseeing Leas Cross.
"It is my deepest regret that a number of patients at Leas Cross were injured during their residency in the nursing home and that our board was unable to have in place sufficient robust oversight systems that might have identified and resolved the deficiencies in care that we now know existed."
The Director of Primary Community and Continuing Care with the HSE, Aidan Browne, said the HSE, which took over the functions of the NAHB in January 2005, shares that regret and is making every effort to ensure that what happened at Leas Cross does not occur again.