THE HEALTH Service Executive (HSE) has been ordered by the Ombudsman and Information Commissioner to pay €5,000 to the family of a 53-year-old woman over an unacceptable delay in the examination of a complaint they made following her death.
The woman, a mother of two who had been attending Mayo General Hospital as a public patient, died four days after undergoing lung function tests at Galway’s Merlin Park Hospital in December 2004. Her abnormal results from these tests were send by ordinary post to a consultant gastroenterologist at Mayo General but remained in his postbox unopened until her GP contacted the hospital 10 days after she died.
The family was anxious to ascertain if the woman would have survived had her abnormal test results been opened earlier at Mayo General. Ombudsman Emily O’Reilly, in an investigation into the case published yesterday, found while “the maladministration which occurred” did not lead to the woman’s death, there were systems failures in her case which needed to be addressed as a matter of urgency to prevent risk for other patients in future.
Her report outlined how the family of the woman, who wish to remain anonymous, first complained to her consultant at Mayo General but, while waiting for a response, his staff issued the dead woman with an appointment to attend for a further test at the hospital. This was four months after she had died, causing them further distress.
They were also caused distress when their mother was issued with a medical card renewal form by the HSE, 11 months after her death. This was despite the fact that she had died in a HSE ambulance on her way to the Castlebar hospital and had undergone a post mortem at Mayo General.
Ms O’Reilly, who recently spoke about one aspect of the case at a conference in Dublin, said the dead woman had initially presented with breathlessness and weight loss and suffered from Raynaud’s disease. But she was able to walk in and out of the Galway hospital for her lung function tests, and staff there and in Mayo said there was no indication her death was imminent.
Ms O’Reilly was concerned abnormal test results could be left lying around in a consultant’s pigeon hole for a few days, and by the fact letters were sent to a deceased person by a body investigating her family’s complaint and that her consultant in Mayo, when asked for her lung function test results after her death by her GP, provided an incomplete copy of them. She found it was “inappropriate” for the consultant to omit an integral part of the results from what was sent to the GP. When interviewed, the consultant could not explain this.
There was also a conflict of evidence in relation to how post was treated at Mayo General. The consultant said all mail addressed to him went to his private secretary but the dead woman’s test results ended up in a pigeon hole in the hospital, used normally by consultants’ public secretaries. The letter containing the woman’s test results was not date-stamped on arrival at Mayo General. Her consultant at the hospital said there were often delays of several days before test results would arrive back, though staff in Galway said they were posted immediately to Mayo as they were abnormal.
The consultant, when interviewed, acknowledged that “on occasion it could be up to a week before he might review his post” from his pigeon hole in the public secretaries area. He also acknowledged the test results “might have gone unnoticed for a longer period” had the GP not phoned.
A copy of the report has been sent to the Medical Council. The HSE apologised to the dead woman’s family and said it would implement the ombudsman’s recommendations.