A WOMAN WHO died in a Limerick hospital was not seen by a nurse or a doctor for 7 hours on the day of her death, even though she rang her son to tell him that she was dying.

Ombudsman Emily O’Reilly, who investigated the case, found that problems with the hospital’s record-keeping meant that the woman’s family were not with her when she died.

The woman had phoned her son at noon on the day she died, asking him to come to the Mid-Western Regional Hospital in Dooradoyle where she was being treated. He arrived at 1.30pm, but was not briefed by medical staff about the seriousness of her condition until around 5.45pm.

His mother died at 11.30pm that night. The delay in telling the man how ill his mother was meant that no-one else from her family was able to travel to the hospital in time to be with her before she died.

The Ombudsman began an investigation in response to a complaint from the man, who said that the hospital was unable to provide evidence that a doctor or nurse had seen his mother between 9am and 5.45pm on the day of her death, meaning that the family were not able to be informed about her condition.

After an investigation, the Ombudsman found several deficiencies with how the hospital kept patient records – especially because medical notes had no time stamp on them – meaning the Mid-Western Regional Hospital could not confirm if the woman was seen by staff on the day in question.

After reconciling the nursing notes with the medical staff notes from the date, the Ombudsman noted that “on the balance of probability, the patient was not seen by the medical team in the period 10am to 4.30pm on the day she died”.

“You can imagine how distressing this was for the family,” O’Reilly said today.

The hospital has since introduced a policy on contacting the next of kin when a patient’s condition deteriorates after the incident. The Ombudsman also asked the hospital to consider whether an apology was warranted to the family and, following the request, the Mid-Western Regional Hospital apologised for the hurt and distress caused to the family.

The case was one of a number highlighted by the  Ombudsman Emily O’Reilly in her final annual report today on complaints made about public bodies.

Complaints

The Ombudsman received 3,412 complaints in total from the public this year – a small drop from the record number of complaints received in 2010 (3,727) but still higher than the ten-year average of 2,774.

The public bodies which received the most complaints were the Department of Social Protection and the HSE, although O’Reilly pointed out that both bodies deal with huge numbers of people on a daily basis.

Some of the other significant cases which were resolved last year included:

• A man received €68,000 backdated from the Department of Social Protection after he was not informed that he could apply for a survivor’s pension following the death of his wife. The Ombudsman found that the Department knew that his wife had died because he had changed the name of the child benefit claimant a year after he death, but had not informed him of his pension entitlement. The Department initially only backdated the money to 2006, despite the fact that his wife died in 1998, but this was overturned upon investigation.
• A woman who was incorrectly diagnosed with a serious heart condition called Long QT syndrome which can lead to sudden death was refused a second opinion over her diagnosis and ended up paying €1,000 for a private consultation. The HSE apologised for not allowing her a second opinion and refunded her the costs after an investigation. The second opinion confirmed that the woman did not have the condition.
• A man who was told that he would still receive social welfare payments if his family moved to Guernsey – where his wife had been offered a job – was given an ex-gratia payment of €1,000 by the Department of Social Protection and an apology after he discovered that he could not, in fact, receive social welfare payments as Guernsey is outside of the European Economic Area

O’Reilly also pointed to SUSI, the third-level grants body, which has been the source of a number of complaints to her office this year over long delays for students.

“A lot of hardship has been caused to a lot of students” by SUSI,” said O’Reilly.

Reflecting on her ten years as Ombudsman ahead of her final day tomorrow before she leaves for the EU Ombudsman position, O’Reilly said that one of the strengths of the office has been in challenging groupthink among public bodies.

She said that financial constraints faced by public bodies due to the Government’s chosen path of austerity and cuts “is not an excuse for poor service, for inequitable treatment, for denial of rights”.

She also singled out the Department of Health as being particularly difficult to deal with, noting that it remained particularly suspicious of the office of Ombudsman and often seeking legal advice instead of engaging with complaints.

“In a properly functioning system, we’d be able to talk like grown-ups,” she said.

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