HSE made man’s partner feel culpable for death
As a result of the transfer, on November 23, 2007, the man, who had a history of respiratory failure, died within half an hour of arriving by ambulance at the nursing home — because the level of supplemental oxygen he required was not available.
An independent review by UK-based consultancy Verita said: “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.
“At the outset of this report we will state unequivocally that the death of Patient A was both predictable and preventable.”
The report also states “unequivocally” that the man’s partner “bears no responsibility for the events of 23 November 2007”, and that she had cared for him at home for years “faithfully and effectively”.
It also outlines how, despite the circumstances and the manner of the man’s death, a systems analysis investigation was not immediately commissioned by the HSE and the information given following the event to the coroner did not warrant an autopsy and inquest.
An inquest was subsequently held in July 2009, after representations to the coroner from the man’s partner and her legal advisers. It recorded a verdict of medical misadventure.
It was five years after the man’s death when the HSE “first acknowledged (and apologised for) the failure in care provided to ‘Patient A’ when a civil claim relating to the event was settled in September 2012”.
The Verita review was published on the HSE website this week.
The woman issued a response through Independent Patient Advocate Jim Reilly, saying the report “confirms what I have been painfully aware of for the past 10 years — that the HSE did not appropriately address my concerns about this serious adverse event, which Verita describe as... catastrophic failure in healthcare and unacceptable in any advanced healthcare system”.
The woman said what she “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”. Moreover, the HSE’s “constant stonewalling behaviour” over 10 years had been “very distressing”.
The woman said she would be writing to Health Minister Simon Harris seeking a meeting to discuss the report, which she said raised “serious concerns regarding the conduct of clinicians and management within the HSE at many levels”.
