A REPORT into the transfer of a man – who later died from St Michael’s House to Leas Cross nursing home in Swords, Co Dublin against his family’s wishes has highlighted “systems failures” in the decision-making process.
Peter McKenna (60), who had Alzheimer’s disease and Down syndrome, died a decade ago in October 2000, 13 days after he was transferred from St Michael’s House.
A non-statutory inquiry into his transfer to the nursing home was commenced at the request of Minister for Health Mary Harney in 2007.
The report of the inquiry by Conor Dignam BL, which was received by the Health Service Executive (HSE) last March, was published yesterday. It found the process of consultation with Mr McKenna’s family after they were told of the decision to transfer him was “inadequate”.
It did not make any findings of fact in relation to the adequacy of the care Mr McKenna received at Leas Cross.
The decision to transfer Mr McKenna was made in a “crisis situation” which adversely affected consideration of issues such as support for and communication with Mr McKenna’s family.
The report said there were “shortcomings” in the handover of Mr McKenna’s care from St Michael’s House to Leas Cross. “While they should not have occurred, they were not of a nature which were likely to have prejudiced or compromised Mr McKenna’s care.
“There was a systems failure in respect of St Michael’s House system of monitoring and supporting Leas Cross in that a member of staff either witnessed events which should have caused serious concern in relation to how Mr McKenna was being cared for and did not report them back to St Michael’s House, or reported them back to St Michael’s House but nothing was done.”
There was “no adequate assessment” of the suitability for Mc McKenna of the proposed placement in Leas Cross but St Michael’s House did “not knowingly” place him in a facility it knew to be unsuitable.
Mr Dignam said that while he found on balance that Leas Cross was “not a suitable placement”, he did not believe it necessarily followed that this unsuitability led to Mr McKenna’s dehydration, the fact that he had an infection which was missed until October 22nd, or to his death.
Minister for Health Mary Harney said she was particularly concerned about “the distressing lapse in normal procedures” and noted that all of the recommendations have now been implemented by St Michael’s House through “the improvement and strengthening of a series of standard policies”.
St Michael’s House said it was deeply sorry it was unable to provide a place for Mr McKenna due to the lack of State funding and regretted that the family has suffered distress in seeking to find answers to their questions in relation to Mr McKenna’s transfer to Leas Cross.
It noted the Dignam report acknowledged that the physician who certified Mr McKenna’s death was satisfied that his death raised “no cause for concern” and that it was caused by one of the well-recognised complications of Alzheimer’s disease in people with Down syndrome.