A HSE-run nursing home where 22 elderly residents lost their lives to Covid-19, and which is at the centre of whistleblower allegations, breached several infection-control rules, leaving them at higher risk from the virus, an investigation has found.
he report backs up five of 12 allegations made by former healthcare worker Margo Hannon who was working in St Mary’s Nursing Home in the Phoenix Park, Dublin, at the time.
In a statement tonight, Ms Hannon said she welcoemd the release of the executive summary of this report.
But she added that she was left “frustrated and disappointed with the inexcusable delay in getting to this point”.
Ms Hannon said: “It has been over 1,000 days since I submitted my protective disclosure, my main objective being to ensure that the policy failures I witnessed in managing the Covid-19 outbreak during the initial stages of the first wave of the Covid-19 pandemic, could be investigated and lessons learned quickly to strengthen health systems and protect patients in nursing homes during the pandemic.
“I desperately wanted other nursing home managers to learn from our experience in St Mary’s so that unnecessary suffering and fatalities could be averted.
“The fact that it has taken over 1,000 days for the executive summary of this report to be published meant that this core objective is a dismal failure.
“It is equally inexcusable that only the executive summary of this report will be made public. If we truly want a transparent and accountable system then the full report, redacted as required, should be published and I will continue to call for that.”
The review team, in the summary report, said it acknowledged the unprecedented nature of what the team in St Mary’s were dealing with.
However “the HSE fully accepts that there were a number of issues identified in this report which put residents at further risk of Covid-19 infection at that time”.
The HSE said it would like to acknowledge the important role of the whistleblower in highlighting issues.
Among the five areas of failings were concerns about failures to lock down wards and buildings.
The investigators found that while the need for measures such as social distancing was communicated, it was not monitored and there was evidence that social-distancing guidance was not always adhered to.
The investigators noted, however, they could not find definitively on the suggestion that agency staff moved between wards.
A number of concerns were grouped by the investigation under “conflicting roles of medical, infection prevention and control and nursing management staff in identifying, isolating and testing”.
The review team identified that Covid-19 assessment criteria were applied in a conflicting manner by different staff.
There was evidence that the guidance on daily temperature monitoring was not adhered to.
There was also evidence that cohorting of patients was not correctly implemented due to a misunderstanding of regulatory barriers to this.
Concerns regarding a failure to isolate symptomatic residents were upheld on the basis that in the early period of the outbreak, a small number of patients with dementia continued to move around the facility as they normally would.
It was noted that there were differences in the approach between infection prevention control and older-persons nursing in their response.
This was a particular challenge at the time as the understanding of the symptoms older people were experiencing and IPC guidance were both rapidly evolving.
The whistleblower had raised concerns relating to the movement of some equipment between patients. The report did find that for the most part, the practice in St Mary’s was acceptable. However, the use of a single cordless phone between patients was found to be poor from an infection-prevention and control perspective, and on this basis they upheld this concern.
The whistleblower highlighted concerns relating to the appropriateness of end-of-life care in St Mary’s. While best efforts were acknowledged, the review teams found that communication with two families was inadequate at that time and therefore this concern was upheld.
It was noted that while a communication plan was in place, it was hindered by limited wi-fi and phones not answered on some occasions.
Yvonne O’Neill, HSE national director for community operations, said: “The HSE would again like to offer our deepest sympathies to the families of those residents who passed away in PPCNU during this period. We have been in contact with each of the families of those residents who passed away during this time and have met with those families who wished to meet us.”
It said the timeframe under investigation was at the outset of the Covid-19 pandemic, when new information was emerging daily. The unknowns and challenges right across the health service made it extremely difficult for staff who were providing care.
There were other issues raised by the whistleblower and examined by the review team which were not upheld .
These related to questions about the management of visiting restrictions; PPE supply; the unit’s end-of-life protocol; the risk assessment of vulnerable staff; staff Covid-19 testing policies; the application of annual leave policies; and questions raised relating to the recycled air system.
It made other findings which were not highlighted by the whistleblower.
Nursing notes were limited during the outbreak, while this was to enable greater focus on providing patient care during those challenging weeks, it was not in keeping with best practice, and this impaired the work of the investigators.
An apparent governance and leadership “gap” existed between management and the front line, it said.
The report reflects the efforts that everyone made to try and manage what was an unprecedented situation but at times the management was fragmented.