A Good Death...

A Reflection on Ombudsman Complaints

about End of Life Care in Irish Hospitals

Bernadette McNally

Director General

Office of the Ombudsman

The Ombudsman’s role

Investigate complaints

Seek redress where complaint upheld

Facilitate change / improvement

Is negative feedback a

bad thing???

• The Positivity Ratio

(positive events to negative)

• < 2:1 languishing

• 5:1 flourishing

• > 11:1 a problem !!??

• We all need constructive confrontation of problems and bad behaviours

The Mid Staffordshire scandal:-

Could it happen here?

Mid Staffordshire Inquiry

appalling suffering of many patients

did not listen sufficiently to its patients or staff or ensure action

failed to tackle an insidious negative culture

disengagement from managerial and leadership responsibilities

ascribed more weight to positive information than to concerns

a culture of habituation and passivity

a striking absence of empathy

How did Mid Staff respond to complaints

• 64 serious complaints: all ignored

• The Board lacked an awareness of the reality of care being provided to patients

• Did not respond to warning signs indicating poor care because it gave complaints too little weight

• Failures could be due to inattention, but more likely to be the lack of importance accorded to this information

Heard in evidence 378 times

“with the benefit of

hindsight”

Top Complaints to Irish Ombudsman re Healthcare

Care of the Dying

Assistance with feeding

Toileting and continence

Falls, Seating & Pressure

Mgt

Hygiene

Drug Administration

Treatment of family

members

Communication

Behaviour of staff

Access to medical care

Staffing levels

Access to Therapies

DNR and other

Record keeping

Complaint handling

Discharge planning

Colin

A son’s death and lessons learned

The Complaint

Regime of anti-biotic Tx

Poor communication

Poor record keeping

No info on side effects and risks

Dehydration and under-

nourishment

Inadequacy of medical care

(frequency and competence)

No cover for Consultant

The outcome

Training on Adv. Drug Reactions

Better communication

Better record keeping

Appt of 2nd Congen. Heart Nurse

Policy on the clinical handover of

patients from one team to another

10

What my Office seeks...

High standards

Where failings occur,

-manage the complaint locally:

-acknowledge the failings,

-apologise (meaningfully)

-provide assurances re improvements

If complaint escalates to us, cooperate

fully, and in a timely manner

Learn and Lead

A collection of stories

and experiences.

What can we learn

from them?

DNR

Older woman cared for “poorly” in hospital

Family complained and sought medical records

Family had agreed to DNR, but was not aware of “

comfort measures only”

Family believed it had caused death by medication

etc. being withdrawn

Learning:- Better communication, explanations,

responsibility of consultant, copies of relevant policy

Breaking bad news

87 yr old woman told she was dying of cancer

No family member or nurse present

(Family had asked Reg. not to give bad news)

Learning

Policy on breaking bad news ( how, when, who...)

Give it time

Respect wishes of patient, be aware of family

concerns,

Supporting a good death at home

85 year old woman discharged home 6 days

before death

No visit from PHN for first 5 days (no referral)

Pain relieving meds not available for first 24 hrs

No advice on care

Learning

Actively plan and support the d/c and logistics

Activate community resources

Duty to family?

Information.... Patient’s rights versus family regrets

Space to grieve

Offering condolences

Patience and tact

Arranging post mortems

The remains

The mortuary

Managing complaints

Complaints re care before or after death are

sometimes the most complex and time consuming.

Give them time early on.

Offer a non-threatening meeting, perhaps with an

advocate present.

Listen. Work hard not to be defensive

Where there is learning, show strength in pursuing it

"I wanted to thank you for everything you have done

over the last few years.

If it wasn't for you I would still be living uncertain of

what happened, with myself and my kids re-living

every thing that happened for the rest of our lives.

Every day was an emotional roller coaster.

It is like a dark cloud has been lifted. Its finally over

and I can enjoy my life. I have some issues still to

deal with as a result of what I went through but

this is the start of my next chapter".

Complainant to complaint investigator

Thank you

www.ombudsman.gov.ie

Lo-call: 1890 223030

Ombudsman@ombudsman.gov.ie

and also see www.