NEWS

Ombudsman receives over 3,000 complaints about public services – 79 from Donegal

Case study: Delays in hospital transfer of elderly man and his family not informed of falls

Staff Reporter

Reporter:

Staff Reporter

Email:

editorial@donegaldemocrat.com

Ombudsman report

Letterkenny University Hospital

Details have emerged of how a man complained about a 12 day delay in arranging a transfer for his late brother from Letterkenny University Hospital to University Hospital Galway, the regional centre, for a urology review.

His brother’s condition deteriorated before a transfer occurred and he later passed away.

The case has been included in the Ombudsman’s annual report for 2017 which focuses on complaints made against providers of public services last year.

Ombudsman Peter Tyndall received 3,021 complaints about providers of public services last year.  79 complaints were made from people living in Donegal. The Ombudsman’s annual report for 2017 was published today (Wednesday)  and shows that the sectors that were the most complained about in 2017 were:

Government Departments/Offices 953 complaints
Local Authorities 852 complaints
Health and social care sector 608 complaints
 

The Ombudsman received an increased number of complaints about the local authority sector in 2017.  This was as a result of a rise in planning enforcement complaints (114 in 2017 compared with 95 in 2016) and housing cases (379 compared with 364 in 2016).

Donegal County Council received 39 complaints about its services.

The Ombudsman also announced today that he will shortly be publishing a report into ‘end of life care’ in Irish hospitals.  The report is expected to show the progress that has been made since his commentary on complaints about end of life care - ‘A Good Death’.


CASE STUDY

Delays in transfer of elderly man and his family not informed of falls

A man complained about a 12 day delay in arranging a transfer for his late brother from Letterkenny University Hospital to University Hospital Galway, the regional centre, for a urology review. His brother’s condition deteriorated before a transfer occurred and he later passed away. The man felt that not enough was done to ensure the transfer happened. In addition, his brother suffered a number of falls while he was in hospital. The family complained that they were not told about all the falls.

Examination

The man suffered four falls while in hospital. He received treatment after each fall and an orange band was placed on his wrist to indicate he was at risk of falling. However, no particular actions were taken to prevent him falling again, documentation was incomplete and the family was not notified of all the falls.

The urology team in the regional centre accepted the man for transfer but his name was not added to the bed management list in the regional centre until 13 days later. The local hospital rang most days to see if a bed was available and wrote in the bed management log book ‘no bed’ or ‘not on list’. They were not aware, until the Ombudsman’s examination, that the man’s name had not been put on the list.

At one stage the team in the regional centre said the man was not suitable for transfer until more tests were done. The family was not aware of this.

It was clear that there was no agreed protocol covering the procedure for the transfer of patients between the two hospitals. The consultant had little involvement in the transfer and all dealings were by telephone which resulted in serious communication issues.

After waiting 12 days for a transfer, the family complained. The consultant rang the regional centre and the man’s name was then added to the transfer list. Sadly, the man soon become too unwell for a transfer to take place.

Outcome

The Hospital Group committed to finalising a Bi-Directional Patient Flow policy to streamline the process for transferring patients within the hospital group. The importance of clear documentation and communication in arranging transfers was to be included in induction training for hospital doctors.

The local hospital formalised a new falls management policy and specialist ‘Frailty’ training, which includes a module on falls prevention and management. This was rolled out to all nursing staff in the local hospital.

The General Managers of both hospitals wrote to the family and apologised.