The widow of a Co Meath man who died of sepsis less than three weeks after being admitted to hospital from a private nursing home, with a head wound infested with maggots, says a HSE-commissioned report has delivered “no justice, no accountability and no closure”.
Mary Bartley-Meehan’s husband Ultan Meehan (79) died on June 15th, 2020 in Connolly Hospital, Blanchardstown, having been transferred by ambulance from Kilbrew Nursing Home in Ashbourne on May 29th.
He had dementia and carcinoma cancer, which resulted in tumorous wounds on his face and head, and had been resident in Kilbrew since February 2019.
Subsequent to Mr Meehan’s time in Kilbrew nursing home, it came under new ownership and management in 2021.
The unpublished report, conducted by independent patient-safety consultant Cornelia Stuart, finds Kilbrew “[failed] to provide care appropriate to the specific dementia care and wound care needs of [Ultan Meehan]”.
Titled a “systems analysis review” it was commissioned by the Health Service Executive (HSE) at the request of then minister for health Simon Harris and subsequently sanctioned by Minister Stephen Donnelly. The HSE agreed to commission it “in line with the requirements of [its] Incident Management Framework”, a spokeswoman said.
This was despite the HSE having no jurisdiction over private nursing homes, and in light of the fact that the regulatory body, the Health Information and Quality Authority (Hiqa), then had no remit to investigate individual cases.
In addition, the HSE’s local safeguarding office had no function to investigate concerns in a non-HSE, non-HSE-funded facility.
Completed in February, the report makes 24 recommendations around the specific care needs of dementia patients. wound management, communication and note-keeping, and the role of HSE safeguarding officers.
It notes a key “missed opportunity to identify possible infection”; “failure to try to understand and effectively manage” Mr Meehan’s dementia-related behaviours; failure by Kilbrew staff “to establish and maintain a trusting relationship” with Mrs Bartley-Meehan; “inconsistent use of [morphine]” to manage Mr Meehan’s pain to facilitate cleaning his wound; and the absence of key information in nursing notes.
Speaking to The Irish Times in the past week, Mrs Bartley-Meehan describes her ongoing trauma, nightmares, guilt and grief about Mr Meehan’s last 16 months, and final months in particular.
“My biggest regret is I allowed him to go in there, and they [Kilbrew] took him when they weren’t able to look after him. But I felt like I had no choice,” she says.
Mr Meehan had been diagnosed with vascular dementia in 2012. By 2020 Mrs Bartley-Meehan was “terrified” he would wander from the house at night. She knew Kilbrew did not offer specialised dementia care but on February 6th, 2020, when he left a respite placement, she had just two days to decide, as approval for the Fair Deal scheme was about to expire.
The report notes: “One of the key issues of [Kilbrew] in providing a dementia-specific service to [Mr Meehan] was a failure to try to understand and effectively manage [his] needs-determined behaviour (NDB).
“People with dementia are often unable to recognise or verbalise their feelings and act on their emotions instead. Their behaviour is a result of a need not being met.”
Notes from the home refer to Mr Meehan’s “noncompliance, verbal abuse, acute agitation and physical aggression”, says the report. “The review team are concerned that all these words are from a negative perspective rather than trying to understand [what Mr Meehan was trying to communicate]”.
Mrs Bartley-Meehan understood her husband and could calm and care for him, but was unable to do so at home without support, she says.
Her son, Adrian Bartley, who had Down syndrome and died of pneumonia in March 2020 aged 52, was already in KIlbrew nursing home as a more suitable residential care setting could not be found for him. It is about 30km from her home just outside Navan.
“They were so far away – a 40-minute drive – but I always brought them home at weekends to bathe them and wash their hair, cut their nails. Then you see when Covid came I couldn’t visit, I couldn’t bring them home.”
On May 14th, 2020, after Adrian’s death and amid Covid social-distancing rules, she was granted an outdoor visit with her husband.
She was “shocked” at his dishevelled condition – in dirty clothes, his late stepson’s jumper and shoes that were not his. His head wound was “open ... and had an extremely foul smell which I will never forget – like rotting flesh”. There was “black, congealed blood” and “puss”. She took photographs and brought these to Sage Advocacy, which supports older and vulnerable adults and their families.
“He looked very unkempt and appeared distressed ... His nails were partly broken, long and filthy with congealed blood from scraping his wound.” She cut his nails.
Over the following fortnight she, her Sage support worker Maureen Finlay and a primary care social worker asked by phone, email and letter that he be assessed for transfer to hospital. Ms Finlay says Kilbrew told them he was being given the same standard of care as he would get in a hospital.
Eventually, after “movement” was noticed in his head wound on May 28th, Mr Meehan was transferred to hospital, on May 29th, 2020.
A video taken in Connolly hospital’s emergency department that evening, seen by The Irish Times, shows dozens of maggots wriggling and falling from a large, deep, open, wound on Mr Meehan’s left forehead.
Mrs Bartley-Meehan spent an hour with him the day he died. “It is of some comfort to me to know he was clean, pain-free; to know how peaceful and well cared-for he was there,” she says.
The report devotes a chapter to gaps in safeguarding for residents of private nursing homes. The local HSE safeguarding officer told the review she had received “reports of concern” from Connolly hospital “in relation to the maggot infestation”.
The officer said, however: “HSE safeguarding has no jurisdiction over private nursing homes especially when the person allegedly causing concern was a staff member ... her advice was for such concerns to be directed to Hiqa.
“Hiqa in turn advised that they contact the local safeguarding team ... The review team are of the opinion ... this case highlights a gap in remit of Safeguarding Teams in relation to concerns raised in respect of private nursing homes.”
It recommends, “the Department of Health consider the need to extend safeguarding policies and structures in the health and social care sector to comprehend private care providers”.
Mervyn Taylor, chief executive of Sage, says the case “should give everyone pause for thought” about how vulnerable private nursing home residents are if things go wrong for them.
“With the development of new regional health authorities just months away we have to ensure that all nursing homes are brought within a robust system of clinical governance and oversight, with the potential for rapid intervention where necessary.
“We also need to ask ourselves if the ‘regulate and inspect’ approach [led by Hiqa] to nursing homes is sufficient. Greater clinical and practice support skills need to be available to nursing homes which are struggling and if those supports are resisted, then they deserve to be closed.”
The Patient Safety (Notifiable Incidents and Open Disclosure) Act 2023, signed into law by President Higgins last month, provides additional powers to Hiqa to investigate individual complaints. A Hiqa spokesman, welcoming the enhanced protections for private nursing home residents, said, however, that “the details of how [the Act] will be operationalised have yet to be determined”.
A spokeswoman for the HSE said: “The HSE submitted the review report to the Department in late February 2023 ... The Department are liaising with the relevant parties on progressing the recommendations.”
Mary and Ultan had been married for 24 years when he died. She had been a widow five years, with two sons when she met him in 1994. “He was a painter decorator in the Holy Ghost Fathers, in Navan. That’s where I met him. I was a cleaner and cook. Two years later we got married there. He was very quiet, never raised his voice. He loved to look after the house. He loved the country, loved to be out in the air.”
While the report may improve standards in private nursing homes, she is unhappy with it. “There is no accountability. If a farmer did that to a poor cat or poor dog they would have been prosecuted. But nothing. No one is apologising. I’d like someone to say they’re sorry and to admit it shouldn’t have happened. There is no justice for Ultan here.”
Former chief executive of Kilbrew, James Keeling, said in 2020: “At all times, we work to provide the best of care to every resident, who each have a dedicated GP assigned to them.
“Kilbrew Nursing Home, like many others, has been under acute pressure in the midst of the pandemic and its managers and staff have and continue to work extremely hard to deliver the best in care for all of its residents.”
The home is now owned and managed by Orpea Residences Ireland, which declined to comment.