A report into the transfer of a man from St Michael’s House to Leas Cross nursing home in Swords, Co Dublin against his family’s wishes has highlighted “systems failures” in the decision-making process.
Peter McKenna (60), who had Alzheimer’s disease and Down syndrome, died a decade ago in October 2000, 13 days after he was transferred from St Michael’s House.
A non-statutory inquiry into his transfer to the nursing home was commenced at the request of Minister for Health Mary Harney in 2007.
The report of the inquiry by Conor Dignam BL, which was received by the Health Service Executive (HSE) last March, was published today. It found the process of consultation with Mr McKenna’s family after they were told of the decision to transfer him was “inadequate”.
It did not make any findings of fact in relation to the adequacy of the care Mr McKenna received at Leas Cross.
Mr Dignam’s report said there was “an absence of forward planning” for Mr McKenna’s needs in the period leading up to the decision that he should be transferred. The decision was made in a “crisis situation” which adversely affected consideration of issues such as support for and communication with Mr McKenna’s family, and “adversely affected the level of consultation with his family”.
“There was no advance notice or consultation with Mr McKenna’s family in relation to St Michael’s House’s decision.
“This, together with the absence of forward planning, led to an environment of lack of trust.”
Mr Dignam noted that members of Mr McKenna’s family complained they had been treated “contemptuously” by St Michael’s House when they opposed the proposed move to Leas Cross.
He found that while that was their perception, they were “not in fact so treated” and St Michael’s House was not closed to the family’s suggestions.
The report said there were “shortcomings” in the handover of Mr McKenna’s care from St Michael’s House to Leas Cross.
“While they should not have occurred, they were not of a nature which were likely to have prejudiced or compromised Mr McKenna’s care.”
Mr Dignam said he did not conclude that St Michael’s House “reneged on its commitment to provide clinical backup”.
“There was a systems failure in respect of St Michael’s House system of monitoring and supporting Leas Cross in that a member of staff either witnessed events which should have caused serious concern in relation to how Mr McKenna was being cared for and did not report them back to St Michael’s House, or reported them back to St Michael’s House but nothing was done.”
There was “no adequate assessment” of the suitability for Mc McKenna of the proposed placement in Leas Cross.
The report said: “While St Michael’s House had grounds for believing that Leas Cross would be a suitable placement for Mr McKenna, and did not knowingly place Mr McKenna in a facility which they knew to be unsuitable, on balance the placement was not suitable for him and that unsuitability was not identified because of an inadequate system of assessment.”
The report recommended that insofar as it was necessary to use an external facility, including a private nursing home, formal and documented criteria to assess and evaluate such facilities be applied.
Mr Dignam said he did not inquire into the systems that are currently in place in St Michael’s House or whether external residential facilities are currently being used, although there were some references to there being a possible need to do so.
He said he did not consider this to be a proper matter for inquiry given the terms of reference.
He said that while he found on balance that Leas Cross was “not a suitable placement”, he did not believe it necessarily followed that this unsuitability led to Mr McKenna’s dehydration, the fact that he had an infection which was missed until October 22nd, or to his death.
“This is a finding which I cannot make.”
Minister for Health Mary Harney said that while the report found that ultimately the decision to transfer Mr McKenna to Leas Cross was “the correct one in the circumstances”, it also highlighted the deficiencies in the way in which a vulnerable man in care was treated.
She said she was particularly concerned about “the distressing lapse in normal procedures” and the way in which St Michael’s House failed to communicate with Mr McKenna and his family.
She noted that all of the recommendations have now been implemented by St Michael’s House through “the improvement and strengthening of a series of standard policies”.
The HSE said it was satisfied St Michael’s House had “robust policies” in place in relation to the use of external facilities, including the assessment of private nursing homes, decision-making processes; handover procedures; definition of roles and functions of staff; and contingency planning.
HSE regional director Stephen Mulvany said the executive sympathised with the family for the distress they had endured over 10 years in seeking to have their questions answered in relation to their brother.
In a statement, St Michael’s House said that as Mr McKenna was a ward of court, the ultimate decision in relation to his transfer was made by the High Court.
It was deeply sorry that it was unable to provide a place for Mr McKenna at that time due to the lack of state funding and regretted that the family has suffered distress in seeking to find answers to their questions in relation to Mr McKenna’s transfer to Leas Cross.
It noted the Dignam report acknowledges that the physician who certified Mr McKenna’s death was satisfied that his death raised no cause for concern and that his it was caused by one of the well-recognised complications of Alzheimer’s disease in people with Down syndrome.
Fine Gael health spokesman Dr James Reilly said the words “systems failure” had become familiar to those observing patient safety issues such as the ones that unfolded at Leas Cross.
Fine Gael TD Fergus O’Dowd, who campaigned on behalf of Leas Cross families, said he hoped the publication of the report would bring closure to Mr McKenna’s family.
“It has certainly been a long time coming – the 10th anniversary of Peter’s death is next week.”
Leas Cross closed in August 2005 shortly after RTÉ's Prime Time Investigates sent an undercover reporter into the home and found serious problems. It was subsequently sold and has since reopened under new management and a new name.