Galway Hospice Foundation has been effectively closed to new patients for a year. Lorna Siggins reports.
IT is a conspiracy theorist's dream - but a nightmare for patients, families and those who toiled over a decade to raise €10 million and more in voluntary donations for the Galway Hospice. The Western Health Board's (WHB's) handling of the hospice controversy has ensured that it will become a political issue in the Galway West constituency during next month's local elections.
A "scandal" is how the chairman of Galway Hospice Foundation, Dr Richard Joyce, describes it, and his trenchant criticism of the WHB reflects a growing anger among hospice staff, supporters and the public - one year after the 12-bed unit at Renmore was effectively closed to all new patient admissions. This occurred after the hospice's clinical director and sole referring authority, Dr Dympna Waldron, stopped referring patients to it on the basis of concerns about a number of errors in the administration of drugs to patients.
Dr Waldron, who took this decision last May, has become increasingly isolated over her recent decision to withdraw from all negotiations aimed at resuming referrals. Dr Waldron had been involved in talks to implement the recommendations of the recently published review of medication procedures at the hospice.
The Irish Hospital Consultants' Association (IHCA) says that Dr Waldron will not be returning to work at the hospice "for the time being" for health reasons, while she will continue to work as palliative care consultant for seriously ill cancer patients at University College Hospital, Galway (UCHG).
Dr Waldron will make no press comment, but sources close to the negotiations believe that one of her main concerns is the fact that allegations of bullying made against her by hospice staff from April 2002 are still on the agenda. The WHB was criticised in a Labour Court ruling earlier this year for delays in investigating one of the claims of bullying against her, while it in turn has blamed Dr Waldron for holding up the investigation in another bullying claim. Dr Waldron has denied all claims of bullying.
At last week's monthly WHB meeting, health board chief executive Dr Sheelah Ryan said the board's own investigation into bullying allegations was due to conclude in a matter of weeks, and the complainants were due to be interviewed shortly.
The only factor delaying re-opening of the hospice unit to terminally ill patients is the absence of the clinical director. New pharmacy, nursing and medical protocols drawn up by the hospice are virtually ready to be signed off by the multidisciplinary team, which included Dr Waldron, Dr Ryan confirmed.
A further insight into complications was given at last week's WHB meeting when it was pointed out that a facilitator was to have been appointed for the multidisciplinary negotiations aimed at re-opening the beds. It is understood that the facilitator was proposed to try to overcome a level of hostility which had prevailed at meetings involving the multidisciplinary team.
Establishment of the multidisciplinary team was one of the key recommendations of the independent review of the hospice, commissioned after Dr Waldron stopped all referrals, which was published on March 16th last.
That review upheld Dr Waldron's concerns about medication errors at the hospice in five instances, and found that drug errors were made by both medical and nursing staff during an 18-month period to May 2003. In four cases, emergency intervention was required to sustain life.
However, the review highlighted lack of communication between medical and nursing staff as a key causal factor. It said that nursing staff had raised concerns about procedures as far back as 2000. And it was also critical of medical management for failing to provide adequate training for administration of the drug hydromorphone, and for a breach of procedure in relation to reporting medication errors.
Page 74 of the review states that the acting chief executive officer - who was also manager of palliative care services at the time - was informed in only two of the 17 instances of medication error reported by Dr Waldron. "The reasons given for this breach was that the consultant objected to the manager of palliative care services receiving confidential clinical information," the review states. "This breach of policy on the ground of patient confidentiality is mistaken and clearly inappropriate."
It says that there is a clear requirement for the manager of services to be informed of any potential adverse incidents - not just relating to medication - to protect the interests of the patient and the organisation.
The Galway Hospice has gone through two chief executives, both of whom resigned, and has recently appointed a third, since Dr Waldron became palliative care consultant at Renmore. Up until then the hospice had been a GP-led service, initially built around its homecare team - which has been working throughout the crisis.
Initiated in 1986, the campaign to build a hospice in Galway encountered many obstacles before the purpose built in-patient unit at Renmore was able to admit its first patients in late 1997. In the interim, there were countless events to raise money.
Part of the battle related to the fact that the hospice would not be run by any religious order - and could pose competition for churches relying on donations and bequests. Dr Sheelah Ryan's predecessor at the WHB did not support the concept, and it took four years of lobbying, after the building was completed in 1993, before it secured sufficient State funding to open. The WHB supports it to the tune of more than €2 million annually.
There was much excitement when the post of palliative care consultant was signalled, shortly before the President, Mrs McAleese, performed the formal opening in 1999. From early on, however, Dr Waldron was involved in clashes with senior management, according to hospice sources. Confrontations also began to occur with nursing staff.
"It had been a very happy place to work," said one former employee. "Dr Waldron is an excellent doctor, who would visit patients at 2 a.m. However, her dynamic and energetic approach to patient care began to put incredible demands on everyone around her."
The first public sign of trouble came in early 2002 when it was confirmed that the hospice's homecare service had been suspended the month before to allow for staff training.
Galway East Fine Gael TD Ulick Burke (now senator) voiced concerns at a WHB meeting in January 2002 that plans might be afoot to integrate the services of the Galway Hospice Foundation into the palliative care services of the WHB. However, Ruan O Bric, then a director and acting chair of the hospice board, said that the "restriction" of the homecare service was to pave the way for a new palliative care strategy. "The hospice focuses on end of life care while the new strategy is more about quality of life," he told The Connacht Tribune.
Details of this new strategy were outlined in a memo sent by Dr Waldron to all consultants at UCHG and Merlin Park hospitals in Galway on February 13th, 2003. "The rationale of a specialist palliative care team to add life to years rather than years to life is best achieved, not with tender loving care, but with tender effective care," Dr Waldron wrote. "For patients and their families to be aware that we aim to deliver evidence-based effective care, it is vitally important that they are aware that the service is a consultant-led service..."
"There appears to be confusion concerning the placement of our service, i.e. most people seem to be under the impression that our service is from the hospice," she wrote. "This is inaccurate, misleading and distressing to patients and their families. The word 'hospice' immediately heralds the sense of 'no hope' to many people... To set the record straight, the consultant-led palliative care service is based in UCHG and outreaches to Merlin Park hospital. The team is a hospital-based specialist palliative care team..."
Dr Padraic O Conghaile, a founding member and first chairman and executive chairman of Galway Hospice, highlights the fact that the hospice services in the WHB are contracting, while such services in other health board areas are expanding. He questions the terms under which the palliative consultant appointment was made by the WHB in the first place - with the consultant being answerable to the WHB but not to the hospice, to which he or she was attached on a part-time basis. "This was unique when this arrangement was made," he says.
Dr Joyce, also a founder member of the hospice and GP in Gort, Co Galway, says the WHB must appoint a locum consultant who can sign off on all the medical aspects of the independent review - thereby allowing the hospice to admit new patients. "No private company could ever tolerate a situation like this," he says. While terminally ill patients are receiving excellent medical attention at UCHG under Dr Waldron's care, he says it is not a suitable environment - and it is adding pressure to an acute hospital where there is already a bed shortage.
"It is a fact of life that medication errors occur in all medical institutions, and the review drawn up for Galway Hospice should ensure that it becomes a world-class facility when the recommendations are implemented," Dr Joyce says. "That's what we want to do, but it takes time. The tragic reality of this impasse is that the patient is being completely overlooked."