Mayo General Hospital has agreed to implement the recommendations of Ombudsman Emily O’Reilly following her investigation into the death of a 53-year-old woman. The woman’s family brought their complaint to the Ombudsman after they were unsatisfied with the way the hospital had carried out an investigation into a complaint they made following her death.
The 53-year-old mother of two who had been a public patient at Mayo General, died four days after undergoing a lung function test at Merlin Park Hospital in Galway after being referred there by a consultant from Mayo General. The results of the test carried out in Galway, which showed abnormalities, were sent by post back to Mayo General where they were left unopened in a postal slot for the consultant in the hospital typing pool until 10 days after the woman’s death. It was only after the woman’s GP contacted the hospital that the results were opened.
The family of the woman wanted to see if she would have survived if the results had been opened before she died. The Ombudsman’s report found that while maladministration did occur, it did not lead to the woman’s death. The family of the woman made a number of inquiries of the consultant and were told that it was being looked into. While they awaited a response an appointment card for the deceased woman to attend for a further test was issued, four months after she died, and then 11 months later an renewal form for a medical card was issued to the deceased woman, which caused further distress to the family.
The Ombudsman expressed concern that abnormal test results were left sitting in a postal slot for 10 days before they were collected, and that an appointment reminder and medical card renewal form were issued to the woman while the HSE was supposedly carrying out an investigation into the family’s complaint. She also commented on the fact that the woman died in an HSE ambulance on the way to the hospital and that a post mortem was carried out at the same hospital on the woman, yet the HSE still sent these forms out to her.
Ms O’Reilly also said that it was “inappropriate” for the consultant to omit part of the lung function test results from what was sent to the GP and that the consultant could not explain this. The report also found a conflict in evidence as to how post is delivered to relevant consultants in the hospital, with the consultant saying that all mail addressed to him was sent to his private secretary who would bring it to his attention, yet the results were placed in a postal slot in the typing pool in the hospital normally used by the consultants’ public secretaries. The letter with the test results was not date stamped when they were received. The Ombudsman recommended that the family of the deceased woman be awarded a payment of €5,000 for the anguish they suffered after the woman’s death and that senior management of the hospital meet with the family of the deceased woman and apologise to them for their shortcomings during the series of events.
A HSE spokesperson confirmed that the HSE had met with the family members and apologised to them and that it was putting in place measures to implement the recommendations of the Ombudsman’s report to ensure that all test results are handled efficiently and acted upon by the relevant doctors.
