Leas Cross Report: Failure piled on Misery

It took some time to read and digest the full 300+ page Leas Cross investigation report. In the deluge of An Bord Snip coverage it made sense to leave a post until this morning. In the cold light of morning the report is worse than the initial impression my dulled senses took. There are a litany of problems exposed in a lengthy report into how Leas Cross was set up as a private nursing home, had its licence renewed, its capacity extended and subsequently evaded inspections and mistreated patients.

Inspectors had long raised concerns over the size of the home and its staffing levels, despite concerns and a complaint registered against the home it was relicenced in 2004. For two years (at the very least) the standard of care was below the acceptable level – from 2003 to 2005. This decline came as numbers in the home rose via referrals and overlapped with the period when the HSE relicenced the home and increased bed capacity.

People were found by Prime Time restrained in buxton chairs, in flithy conditions. The HSE went on for a limited, ultimately unpublishable, inquiry chaired by Prof. Des O’Neill. It is not hard to see why. Yesterday’s report hangs the HSE for overlooking a registered complaint about conditions at the home while considering the proposed relicencing. Let us think about that for a second.

As Leas Cross applied to increase capacity, an inspection report raised serious concerns as the process of reregistration took place. No one is named in the chain of events and following the line of General Manager A to Inspector X etc makes for difficult reading, however, the conflict of evidence leaves the commission with one big headache.

It is not possible for the Commission to determine conclusively where ultimate responsibility lay for decisions regarding registration. It is clear from the foregoing conflict of evidence that there was a lack of understanding within the Health Boards to where that responsibility lay, which meant that nobody appears to have been accountable for such important decisions.
…
From the evidence submitted to the Commission, it appears that, once the registration of Leas Cross had expired, it was renewed automatically with no regard to the suitability of the home for re-registration, to previous inspection reports, to outstanding complaints or to the need to impose conditions. In particular, it is clear that the nursing home was re-registered notwithstanding the existence of a erious complaint of which the inspectors and Health Board management were aware….
Nonetheless, it is the opinion of the Commission that the practice of the Health Board in this regard seriously undermined the inspection process and potentially posed serious risks for the residents of nursing homes

So accountability is lacking, the chain of command is all over the place and ultimately decisions made by executives undermined the system of inspections meant to protect patients. Protect patients you say? From what?

The first complaint to the Health Board in 2004 was made on the 15th January by Mary Hegarty regarding the care of her mother, Catherine Mullins. Ms Mullins had been resident in Leas Cross since June, 2003, suffering from Alzheimer’s Disease. Following a number of complaints to the matron at Leas Cross relating to the failure of the staff to understand the needs of an Alzheimer’s patient, an incident occurred in January, 2006 which persuaded the family to move their mother elsewhere. Ms Hegarty visited the home to find her mother slumped on a couch in the foyer, in pain and wearing soiled clothes. She received little assistance from the staff in trying to help her mother and she also found that her mother’s medication had been left in her room. The family removed Ms Mullins from Leas Cross a few days later.

This is private enterprise folks. There were four complaints in 2004 relating to patients being pushed down the stairs, having raw sewage in their rooms and this final one:

The final complaint in 2004 was made on the 1st October by the husband of a resident suffering from Parkinson’s Disease, who developed a serious bed-sore while in Leas Cross. The family of the resident in question have asked to remain anonymous. The nursing home had been informed at the time the complainant’s wife was admitted that she was susceptible to pressure sores. A serious sore developed on her sacrum, which was treated in the Mater on three occasions in 2004 and recurred despite treatment. A wound specialist at the Mater Hospital asked for better cleaning of the wound by nursing home staff. The complainant ascribes the repeated development of the sore to the fact that his wife was allowed to spend long periods sitting in her wheelchair…
On the 1st October, 2004, the complainant wrote to the Nursing Home Section Manager to complain about the medical care provided to his wife at Leas Cross…
The complainant did not receive a reply to his complaint until the 18th February, 2005, by which time his wife had died…

It goes on, I cannot reproduce them all here so I have extracted the complaints section of the report and embedded the document at the bottom of the page – you can also get it here. The complaints pre-existed the Prime Time exposé in 2005. The HSE knew about the issues but continued the process of re-registering. The inseption process was in pretty bad shape at that point.

In a statement to the Commission one nursing home inspector described the nursing home inspection process in place in 2004 / 2005 as having “major deficiencies”, including the following:

• Staff involved in Nursing Home inspections were covering “many other duties” in addition to their inspection work.

• The Nursing Homes (Care and Welfare) Regulations 1993 were “vague and unspecific.”

• The guidelines provided to inspectors “…did not set out basic clinical standards to be expected in nursing homes and there were few clinical parameters by which nursing homes were to be assessed.”

• Staffing requirements for nursing homes “were not specified.”

• There was “a lack of regulation or clarity” with regard to the role of the inspection team in assessing medical care.

• The level of medical cover necessary in a nursing home was not specified in the Nursing Home Regulations or any HSE guidelines.

• There were no guidelines regarding training for the post of medical officer in a nursing home.
…
The Commission considers that, in the exercise of the duty of care identified above, a more consistent approach during inspections to examining residents would have identified care-related problems such as pressure sores and dehydration earlier and would have enabled inspectors to ensure that adequate steps were taken by the nursing home to develop prevention procedures and to treat residents where necessary.

The dedicated nursing home inspection team, established in October, 2004, introduced a new inspection form. That form does not appear to have been used in relation to Leas Cross Nursing Home.

I realise at this point I am block quoting a lot, but words of my own would fail to communicate the scale of the failure at Leas Cross. In advance of the Prime Time report, the issues were being aired and the system was failing horribly. Attention to patient welfare was suffering, an atmosphere of untrammeled expansion pervaded and the HSE was happy to continue paying the home in order to provide care. At a high level decisions were taken that were, to say the least, harmful.

To underline this point and in a final piece of blockquoting, I want to share some concerns from the St Itas bed management committee, whose patients they had referred to Leas Cross.

It seems that the Psychiatry of Old Age team continued to have concerns regarding the standard of care at Leas Cross. Amongst the documents disclosed to the Commission is a draft letter dated the 15th July, 2004 from the St Ita’s Bed Management Committee to Nursing Home Inspector H which is headed “Re Leas Cross Nursing Home”. The draft letter states:

“On our previous and recent review visits to Leas Cross, the ambience and décor of the building was pleasant. On interviewing our patients, a percentage of them complained re the inappropriate use of incontinence pads. Another ambulant patient’s shoes were missing for two days. His relatives who were visiting at the time expressed their concerns to us. Four of our patients were sitting in wheelchairs and others in old buxton chairs. General personal hygiene was poor with evidence clearly visible. Their clothes were grubby in appearance and a few patients had a strong odour of incontinence. The heating in the sitting room in the older part of the building was stifling with a large radiator extremely hot.

The staffing appeared inadequate with only one qualified staff nurse and nine care staff caring for sixty five residents in one area, and one qualified staff nurse and four attendants caring for approximately forty residents in another area.

We would like to raise these issues as causes for concern. Many of these issues could be resolved with adequate staffing levels and examination of standards
…”

I want to leave with two elements, the first is this from Carl O Brien in the Irish Times: “But Leas Cross wasn’t alone. There are many others which have been subject to serious concerns or investigation, but never received the same glare of publicity.

St Mary’s, a public nursing home in the Phoenix Park, Dublin, has been the subject of allegations of mistreatment of residents. One such allegation concerns an older person suffering from dementia who had her mouth taped by a staff member to keep her quiet.

The Tara Care Centre in Bray, Co Wicklow, breached care and welfare standards, which led to the disappearance of one of its residents. Health authorities tried closing another nursing home in Dublin over fears that residents were at risk because of improper administration of drugs and staff shortages.

These are just a handful of homes. In an environment where a shortage of nursing home beds existed, in conjunction with a tax incentive-fuelled rush to build new homes, an issues like standards were relegated to one of minor consideration.

Leas Cross was just a symptom of institutional abuse and the State’s laissez fair attitude towards the area. With the exception of some figures, this was a systemic failure by Government, health authorities and other groups to address the issue of appropriate quality of care for older people.”

This is what we should all bear in mind, Leas Cross is not an isolated case, it is the wider problems made particular to one home. For sure it is a worst case but the systemic failure is broad based and the abuse of conditions pervasive as a result.

Consider these conclusions from the report just below and ask whether the publishing of this report yesterday and the subsequent position of the Minister do justice to the scale of the horror uncovered. Fiachra O Cionnaith in the Examiner today has an excellent article on the reaction from families – you will recognise their stories from the report extracts above.
Leas Cross Inquiry Conclusions

This is the section relating to complaints made to the home about care:
Section of Leas Cross Report from Pg 113-122 regarding complaints made