The Health Service Executive (HSE) has apologised to the partner of a man who died almost immediately after being transferred from hospital to a care facility without the required oxygen supply.
It has also acknowledged the deceased’s partner played no role in the decision to transfer him, a matter that had caused her “great distress” since the incident more than 10 years ago.
An independent report into the circumstances of the incident, and the HSE’s response to it, found the man had “suffered what must have been a horrific death without the dignity one would expect in a modern healthcare system”.
“The fact that a catastrophic failure in healthcare occurred has seemed very apparent. At the most basic level, an extremely ill patient was transferred to a setting where, given their requirements and the equipment available on the ground, death was inevitable.”
The deceased, who has not been identified, had a history of respiratory failure and was had been in the care of his partner for about six years. In 2007, at the time of the incident, he was “at the end stage of his illness”.
On November 21st, his condition had deteriorated and he was brought to hospital. Two days later a decision was taken to transfer him to a community unit which specialised in the care of elderly patients.
However, Verita, the independent body hired by the HSE to undertake the review, noted the required level of supplemental oxygen was not available at the community unit and he was pronounced dead within 30 minutes of his arrival.
While a number of reviews have been carried out, the man’s partner was dissatisfied with the response and with the implication of her responsibility for the decision to move him to the unit.
Death predictable and preventable
The Verita report said the death was both “predictable and preventable” and criticised the quality of follow-up action.
A “systems analysis investigation” was not undertaken afterwards and the HSE first acknowledged and apologised for the death following a civil action in 2012.
The partner had submitted a written complaint to the HSE. In 2010, it commissioned a National Incident Management Team (NIMT) review of the case which reported in 2013. "It also failed to address many of the concerns," the Verita report stated.
“A particularly troubling aspect...of our investigation is the effect on Partner B of the suggestion that she somehow ‘forced’ the discharge of Patient A to Community Unit Y,” it said.
“An inevitable consequence of this narrative is that she was culpable in the death of her partner that she had faithfully and very effectively cared for over a number of years.”
It said there was no evidence of a cover up, but the incident should not have been dealt with as a mere complaint, as was the case, but identified as requiring investigation.
In a statement, the man’s partner welcomed the findings saying it was confirmation of “what I have been painfully aware of for the past 10 years”.
“My partner was terminally ill...what I cannot accept is the ordeal they inflicted on him in the last two hours of his life and the awful manner of his death as a result of their decisions and arrangements. This catastrophic failure was then added to by the failures of the HSE to appropriately investigate.”
The partner referred to the HSE’s “constant stonewalling behaviour and attitude”.
In its response, the HSE, which has apologised in writing, said the report showed the patient’s death was a “catastrophic failure of healthcare”.
It stated the partner had no responsibility for the events and that the complaint response from health staff in 2007 had been “completely unacceptable”.