Elderly man suffered 'horrific death' 30 minutes after transfer to public nursing home
Review by HSE found the death of 'Patient A' was both predictable and preventable
An elderly man who was transferred from hospital to a nursing home suffered a “horrific death” that was completely preventable, a report revealed today.
The man died within thirty minutes of being sent to the public nursing home which was not equipped to provide him with oxygen support he needed to breathe.
The review into ‘Patient A’ was published by the HSE today and follows a long campaign by the man’s wife for answers to the tragedy which happened in 2007.
The review found the death was both predictable and preventable and that what happened was a catastrophic failure of healthcare.
He was admitted to hospital late 2007 and was discharged two days later. He was transferred by ambulance from The man was discharged from Ennis Hospital to the HSE-run Regina House Community Nursing home, accompanied by his partner.
Following transfer and after the ambulance left, he died within 30 minutes.
Patient A had specific requirements in relation to supplemental oxygen and the level of supplemental oxygen required was not available at the home.
The review said there was an absence of an acknowledgement from the hospital in relation to the circumstances and manner of his death.
His family submitted a written complaint in December 2007 requesting answers and explanations.
The hospital decided to undertake its initial investigation into Patient A’s death under the organisation’s complaints policy and issued a written response in February 2008.
Following representations from Partner B’s solicitor in April 2008, a further review, was undertaken and the outcome of this communicated to Partner B in October 2008.
The family remained unhappy with the examination of the death over the years and the Director General of the HSE Tony O Brien eventually ordered the independent review.
The review also identifies the effect on the man’s partner of the suggestion in the complaint response issued by hospital in February 2008 that she somehow insisted on the discharge of the patient.
“It must be stated clearly and unequivocally that Partner B bears no responsibility for the events of that occurred in late 2007.
The review said today the way the complaint was responded to in 2008 was completely unacceptable, even by the standards that applied at that time and it failed to follow policies and legislation in place.
Mr O’ Brien has written to apologise to the man’s partner on behalf of the health service for the failings in his care and to state on the record that the responsibility for the events of November 2007 that led to his death resides exclusively with the healthcare system.