Thursday, 2nd March 2023
HSE publishes Executive Summary of Protected Disclosure Investigation at the Phoenix Park Community Nursing Unit, St Mary’s Hospital
The HSE has today (Thursday, 2nd March 2023) published the Executive Summary of a Protected Disclosure investigation relating to a period of time in the Phoenix Park Community Nursing Unit (PPCNU) at St Mary’s Hospital Campus, in early 2020.
The review team upheld issues raised under five of the 12 themes in the open disclosure, and did not uphold issues under seven of these themes. The review team acknowledges 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 would like to acknowledge the important role of the Discloser in highlighting issues. The HSE remains committed to continually learning and reviewing to support making our services safer.
Given the requirement to protect the identity of residents, families and staff, the HSE is precluded from publishing the full report. However, the review team has provided a comprehensive executive summary, which fully represents the issues raised in the full report.
The disclosure, made in May 2020, raised issues concerning events at the PPCNU during a period of approximately six weeks early in the COVID-19 pandemic from early March to mid-April 2020. The HSE commissioned an external expert group to investigate these issues and to provide a report to the HSE.
During this period, there was an outbreak of COVID-19 in the PPCNU at St Mary’s. At that time 83 of the 146 residents of the Unit were confirmed positive for COVID-19 and 22 residents sadly died during this period.
Commenting, 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. They are being provided with a copy of the Executive Summary report and we remain available to answer any further questions they may have. We have also provided details in relation to this report to our current residents and their families, to our staff, and to the solicitor representing the individual who made the original disclosure.”
The timeframe under investigation was at the outset of the COVID-19 pandemic where new information was emerging daily. The unknowns and challenges right across the health service made it extremely difficult for staff who were providing care.
The independent review team identified the following five areas where they upheld issues raised by the Discloser. These include:
- 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, IPC 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 (IPC) and Older Persons Nursing in their response, a particular challenge at this time when the understanding of the symptoms older people were experiencing and IPC guidance were both rapidly evolving.
- The Discloser 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 IPC perspective and on this basis they upheld this concern.
- The Discloser 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.
There were other themes raised by the Discloser and examined by the Review team which were not upheld in this report.
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.
The review made a number of additional findings that did not fall under the themes highlighted in the protected disclosure. These included:
- 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 the best practice, and this impaired the work of the investigators.
- An apparent governance and leadership “gap” between management and the front line. The report reflects the efforts that everyone made to try and manage what was an unprecedented situation but at times the management was fragmented.
Dr Emer Ahern, HSE National Clinical Advisor and Lead for Older Persons Services added, “It is important to state that this disclosure related to a period in Spring 2020 and since then significant changes in both policy and practice have been implemented in St Mary’s PPCNU. The majority of the findings of the investigation relate to infection prevention and control issues and these same issues were also identified by the Expert Panel on Nursing Homes in their report in 2020. The HSE has progressed implementation of the recommendation of the Expert Panel Report across each of its community nursing units including updating infection prevention and control practice.
“Since the disclosure the HSE has launched a new Infection Prevention and Control Strategy and Policy and there are newly recruited infection control staff in place across our hospital, community services and at a national level. The COVID 19 Vaccination Programme has also played a critical role in protecting our residents across all our older persons services.”
Mellany McLoone, Chief Officer, Community Health Organisation (CHO) Dublin North City and County said, “Since the start of the pandemic, we have learned much about COVID-19. Infection Prevention and Control measures have evolved with significant additional resources now in place. This has happened alongside a comprehensive and very successful vaccination programme. These measures have helped protect residents and staff during the past number of years both in St Mary’s and across the CHO. This has occurred alongside an ongoing programme of capital investment and service improvements, including enhanced staffing. These and ongoing initiatives around governance and leadership comprehensively address the themes examined.
“The Review Team have outlined in the Executive Summary the very complex and detailed work they undertook to complete this work. This included 47 meetings with different groups or individuals and an analysis of a very significant number of documents.
“The report may raise memories of that extremely difficult time for the community at St Mary’s and their loved ones. A range of engagements and supports are in place with those directly affected. CHO DNCC are in contact with families who were bereaved from COVID-19 in St Mary’s Campus during the initial wave of the pandemic, current staff and residents and their families.”
Last updated on: 02 / 03 / 2023