Thursday, 26 April 2007
Commission of Investigation into Leas Cross Nursing Home: Motion.
That Seanad Éireann,
bearing in mind the specific matters considered by Government to be of a significant public concern arising from the deaths of residents of the Leas Cross Nursing Home;
noting that the matter raises serious issues about the role and responses of all relevant parties involved in the management, operation and supervision of the nursing home;
noting that it is the opinion of the Government that a commission of investigation represents the best method of addressing the issues involved;
further noting that a draft Order proposed to be made by the Government under the Commissions of Investigation Act 2004 (No. 23 of 2004) has been duly laid before Seanad Éireann in respect of the foregoing matters referred to, together with a statement of reasons for establishing a commission under that Act;
approves the draft Commission of Investigation (Leas Cross Nursing Home) Order 2007 and the statement of reasons for establishing a commission of investigation.
Under the Commissions of Investigation Act 2004, a commission of investigation may be established by the Government, based on a proposal by a Minister, with the approval of the Minister for Finance, to investigate any matter considered by the Government to be of significant public concern. How the State and its institutions protect vulnerable people is, in my view, a significant issue. It is evident a systematic review of the management, operation and supervision of Leas Cross is a matter which falls into this category. As this House is aware, the Health Service Executive, HSE, commissioned Professor Des O'Neill, consultant geriatrician, to carry out a review of deaths at Leas Cross nursing home between 2002 and 2005. This review examined the case notes of those patients who died while resident in Leas Cross between 2002 and 2005 together with documentation from the home, the HSE, the coroner's office, the registrar of deaths and the Department of Health and Children. The report was published in November 2006.
The principal finding of the report was that the documentary evidence was consistent with the care in Leas Cross being deficient at many levels, and highly suggestive of inadequately trained staff, and furthermore no documentary evidence that the management of the nursing home and clinical leadership recognised the ensemble of care provision required to meet the needs of the residents.
This review focused on the care of the patients in Leas Cross nursing home and was a paper-based investigation. It highlighted the importance of promoting the highest standards of care for older people and of ensuring a robust and thorough system of inspections. Action has been already taken to address the concerns raised by Professor O'Neill's report. These include the publication by me in January of draft standards for all long-term residential care facilities for older people which are now going through a consultation process led by the Health Information and Quality Authority, HIQA, and the Health Act 2007, recently passed by this House, which has put the social services inspectorate on an independent statutory footing and which contains provisions to underpin a more robust inspectorial system.
What is required now is a review of the systems in place and the roles and responses of all the main parties involved in Leas Cross. Having considered Professor O'Neill's report the Government is of the view that a commission should be established to investigate this matter, which is clearly of public concern, under the Commissions of Investigation Act 2004. This has been decided taking into account the gravity of the issues outlined by the review and the public interest in the outcome of the review.
The draft order is accompanied by a statement of reasons for establishing the commission, as required by the Commissions of Investigation Act, and a similar motion will be brought before Dáil Éireann. Under the provisions of the Act, the order establishing the commission must specify the matter that is to be investigated. The draft order which is before the House describes this as matters relating to and arising from the review carried out by Professor Des O'Neill in examining the deaths of residents at Leas Cross nursing home, the role and responses of such relevant parties as the commission may determine, including the Health Service Executive, and previously the relevant health boards, regarding the ownership, operation, management and supervision of the nursing home and the circumstances surrounding the transfer of patients from other facilities to the nursing home.
I have already mentioned my recent publication of the draft national standards for residential care settings for older people which update the previous provisions set out in 1993 in the care and welfare regulations. These standards, when finalised, will apply to all residential settings, public, private and voluntary, where older people are cared for and for which registration is required. The draft standards are based on legislation, research findings and best practice. The homes will be inspected against the standards, when finalised after the current consultation process, by the social services inspectorate which is a part of the HIQA. It will be independent in exercising this function.
The HSE is currently carrying out inspections of private nursing homes and produced a report in 2006 on nursing home inspections and registrations. There is now in place a national standardised approach to private nursing home inspections across the country. This currently underpins the inspection process. I allocated an additional €6 million for the further development of the inspection process in 2007 and 2008 and the HSE has informed me that 113 inspections have been already carried out this year. A total of 870 inspections of more than 400 private nursing homes were carried out in 2006. Last year, we funded the largest ever expansion in services for older people with a full-year cost of €150 million and this year, we have gone a step further, with a full-year package of €255 million. In two years we have added more than €400 million to services for older people.
We know that remaining at home is the first choice for older people and Government policy is to support people to live in dignity and independence in their own homes and communities for as long as possible. Where this is not possible we support access to quality, long-term residential care. In this regard it is important that older people have access to the best residential care possible. This Government is committed to ensuring the safety of all our citizens but in particular the most vulnerable in society. A high priority is to ensure the safety of older people who, through their hard work, have put us on the road to the prosperity we have enjoyed for the past number of years. The older population has made an invaluable contribution to all aspects of Irish life. We acknowledge this and we are fully committed to improving all aspects of the lives of older people, not only by focusing on health issues but also by giving consideration to quality of accommodation, security, welfare, and all other issues which affect them.
This is why I am recommending the establishment of this Commission of Investigation. We need to ensure the systems in place for those who are vulnerable and in need of residential care are of a high standard and that they receive quality care and treatment in suitable surroundings. To do this we need to examine the system failures regarding Leas Cross. The terms of reference I have approved will, I believe, result in a focused and timely investigation.
I welcome the Minister to the House and extend my sympathies to her and her party on the untimely death of Senator Kate Walsh. We will miss her greatly and very moving speeches were made by many Senators in the House yesterday. She was loved by all of us here and may she rest in peace.
I welcome the establishment of this commission of investigation as it will give some comfort to families who had parents who died in the care of that nursing home. Many families still have questions in the wake of Professor O'Neill's report that require more complete answers. The families deserve these answers as do all of us. We need to know what went on and why the systems in place failed so badly to care for the residents of that home. We must welcome the fact that the deficiencies in the running of Leas Cross nursing home came into the public domain because it is obvious they existed for some time with many people consequently suffering.
As the Minister said, we all want the best for older people and this is what they deserve. Putting a loved one in a nursing home is the last thing a family wants to do but in some cases it is the only way to ensure a person receives the right care. This is where the problem lies. Families placed loved ones in Leas Cross nursing home with the best intentions but they did not receive the best of care. I am glad we are now to examine the inspections system and to consider how nursing homes are run. It has taken two years to set up this commission and to do so earlier would have been appropriate. I appreciate, however, that Professor O'Neill's report had to be completed first.
My colleague in the other House, Deputy O'Dowd, asked whether the scope of the commission of inquiry's investigations would extend to all patients of St. Ita's Hospital in Portrane who were transferred to long-term care. Given that the commission's terms of reference include the circumstances surrounding the transfer of patients from other facilities to the nursing homes, will it deal with the issue of patients from St. Ita's Hospital who were transferred to nursing homes other than Leas Cross or will it focus specifically on the Leas Cross nursing home?
As a result of changes in society many people are unable to care for older relatives in their homes, as was frequently the case ten, 20 or 30 years ago. Whether it is because society requires that people work or people want to work or whether it is due to a lack of space in family homes, people do not have the wherewithal to look after elderly relatives. The problem will worsen in future. As the Minister and Senators will agree, it is essential, therefore, that nursing homes operate to the highest standards and perhaps we took this for granted in the past. I hope the inspectorate will ensure the standards introduced recently are upheld. Any owner or manager of a nursing home that does not meet the required standards must be dealt with severely.
We cannot afford to have mistakes because those living in nursing homes are elderly and vulnerable and, in many cases, unable to voice concerns. We place so much trust in those who care for the elderly that we must demand of them the highest standards and deal with them severely if they do not meet those standards. I hope this does not become necessary and we ensure standards are met. It is unfortunate that nursing homes must be subject to continuous checks.
I welcome the establishment of the commission of inquiry, as will the families and loved ones of those affected by the Leas Cross scandal, although another investigation will probably cause them further pain. People are entitled to answers and matters such as these must be fully investigated.
I commend the Minister for establishing the commission of inquiry. I am not sure if she referred to a timeframe for the publication of its report. I hope it will not take long because the matter must be concluded as quickly as possible for all the families involved.
I extend my deepest sympathy to the Minister for Health and Children, Deputy Harney, on the death of Senator Kate Walsh. As I indicated in the House yesterday, I knew Kate when she was elected to Kildare County Council many years ago. She was a fine, jovial person who maintained high standards and acted most unselfishly in giving herself to those she represented. May she rest in peace.
I commend the Minister on establishing a commission of investigation into the management, operation and supervision of Leas Cross nursing home. I agree with Senator Terry that this issue has been ongoing for some time. As I stated during a debate in the House on MRSA in hospitals, the problems were operational and arose because people did not do their job. They were either deaf, pretended not to hear or were blind in one eye and could not see in the other. These types of practices must be rooted out of the health service.
Elderly people, who built the State and put us where we are as a nation, are highly vulnerable. It is terrible to think they would receive this type of treatment in the winter of their lives. I use the word "treatment" sparingly because they were not treated to the standards one would expect in a modern nursing home.
The Minister spelled out clearly and concisely what will be the procedures and I welcome the mechanism to close down substandard nursing homes. When standards in a nursing home are found not to be up to scratch how long will it take to close down the home?
I welcome measures for the elderly the Minister has introduced in recent years. In 2006, the budget for the elderly was €1.2 million and the figure will increase this year. The budget for nursing home subvention has increased to €160 million from a mere €15 million in 1994, its first full year in operation. The introduction of 3,000 home care packages is a further important initiative. As anyone involved with the care of the elderly will agree, hospitalising people who are in the early stages of Alzheimer's disease adds to their confusion. It is reasonable to assume the number of home care packages, which will help to keep people in their home environment where they are more easily managed, will be further increased.
The system in Leas Cross failed abysmally. I fail to understand how people could continue to draw their wages while the events in the nursing home took place. In addition, in certain cases it is not possible for a carer to continue providing care for a person in the home because his or her health will suffer if changes are not made. If and when this happens, both ends of the house are on fire.
Since my time in the nursing profession more than 30 years ago, I have raised the infrequency of visits to residents in long-stay nursing homes. This has been a major bone of contention with me. I drew the ire of certain entities when I announced in the House what I believed was happening but I was proved right. For example, in one case a lady who went to visit her favourite aunt discovered that her relative had been dead for 16 years. She had thought about her aunt a great deal without knowing she was dead. Incidents such as this anger me. Will the Minister consider introducing a mechanism to ensure the management of long-stay institutions contact immediate relatives or friends of residents to exhort them to visit their loved ones?
The Society of St. Vincent de Paul has stepped into the breach in the case of long-stay residents of psychiatric institutions. Members of the society have taken residents under their wing, as it were, by visiting them regularly and bringing them little presents, which makes their lives a little easier and better.
I am delighted the Minister has introduced this measure, which is of tremendous importance. I wish it had been done long ago as, if it had been, we might not be discussing what took place at Leas Cross. Let the truth come out in its entirety. Let those who have questions to answer, answer them. There can be no hiding place for them. I compliment the Minister on the establishment of this commission and compliment Mr. Derry O'Donovan, SC, who will report to the Minister within 12 months of the commencement of its work. Well done to all. I wish the commission well.
The Minister's commitment to older people is well recognised. From that point of view, I can do nothing but applaud what she is trying to achieve. I am sure the establishment of the commission is worthwhile but I am concerned about what will happen to the recommendations of the commission. We get report after report but very little action. The major scandal with regard to Leas Cross was not just what happened at the nursing home but also the fact that, two years before RTE's "Prime Time" programme went to the home, a very critical report on Leas Cross was sent to what was then part of the health board but it was not acted on. It is the lack of action on reports that is the real problem.
In our consideration of nursing homes, we must recognise that running costs are enormous. It is now estimated it costs well over €1,000 per week to keep a long-term resident in a nursing home in an urban area.
On a final point, in recent days a coroner's case in Sligo highlighted the danger that exists in transferring people between one medical institution and another if it is not absolutely certain all medical and nursing records are sent with the patient. I suggest the transfer of patients between St. Ita's and other nursing homes was not monitored to the extent it should have been. We must hope this will happen in the future.
There is little I can add to what has been said. The words that attract me in the Minister's contribution are the references to an "independent" statutory body and the "provisions to underpin a more robust" inspection system. There is no doubt we need a robust inspection system and, therefore, what the Minister is doing is correct and she is to be congratulated for it.
There is an assumption that all old people want to stay at home. I can think of two cases, one of which is that of an older person whose clear wish to stay at home is paramount. In the other case, the person wishes to be looked after — I can think of very successful nursing homes which deal with such cases. Let us not simply assume because of the problems that have been created that all nursing homes are at risk of providing poor service. Many nursing homes provide a good, worthwhile service that is much appreciated.
This issue relates to how well we, as a democracy, look after the most vulnerable in our community. The most vulnerable are very often children and those who are not able but they are also those who are aged and unable to look after themselves. In the old story, Quo Vadis, which was later made into a film, the character of the ancient Roman criticised the Christian for his beliefs by saying he did not think much of the way Christianity works. He said that, in his ideal, the God who runs the world would have people come to a certain stage of life and then be lifted up to heaven, with all their friends around them to congratulate them on the job they had done in their lives, instead of getting old and eventually being regarded as somebody who is not able to participate in the way he or she was as a younger person.
The way we care for our aged is very important. In some cases it is much better to be cared for at home whereas in others it is much better to be cared for in a nursing home. If people are to be cared for in a home, we as a democracy must ensure that happens. As Senator Glynn noted, the danger is that when people go into a nursing home, they are forgotten, left alone and not even thought of afterwards by some.
The onus is on the State to deal with this issue. The Minister has taken that onus on herself. She has introduced this inspection system, which I believe is the right way to go. We must make sure we review it rather than simply having inquiries, commissions and investigations. Let us make sure we take action this time. The Minister has taken the right steps, for which I congratulate her.
It is always easy at times like this to have a go at the Government for whatever failings or omissions were identified, particularly those in the area of private nursing home care. However, that is not what I should do in this regard. There is a need to reflect on how negligence and neglect can begin and be allowed to continue in any area of health care, but particularly in the support and care for elderly people.
It would be silly to point a finger at the Minister for Health and Children and claim it is her fault. Many things are her fault but the regime under which private nursing homes were regulated is not one of them. However, there is an underlying issue for which Government has responsibility and perhaps culpability, namely, the question of the apparent slowness, reluctance or unwillingness of families to complain about or demand what they believe are high standards, and the apparent uneasiness of families with regard to the consequences of complaining — I do not mean personal consequences.
In my case, when my mother needed institutional care — she needs it still, thank God — the system worked extremely smoothly through no influence of mine or anybody connected with me. However, I have observed the struggles, travails and trauma of many friends of mine, families I know and people I have met in my political life when the moment arrives and a much-loved parent clearly needs institutional care in some form of nursing home. There is the trauma of the struggle, often unsuccessful, to get subvention and the struggle to pay for the nursing home but, above all, there is the trauma of the struggle to find a place.
Having listened to people talk about the huge trauma of having to care for somebody who is bedridden and incontinent and the sense of life beginning to come back to something like normality because they have found a nursing home place, it is difficult to imagine such people being immediately vocal if they believe standards are not what they want them to be. It is not that they do not love and care for their elderly relatives. It is because they believe the choice is between what is unacceptable and what is an awful lot worse.
What we must do is create a system of support, regulation and inspection which makes the transition possible, where it is clearly necessary. The definition of when a person needs nursing care ought to be one that is capable of being shared by both the family and whoever makes that decision on behalf of the regulatory authorities, in order that we do not have a repetition of the extraordinary stories that arose in the past. For example, although it does not relate to this issue, there is the famous case involving excise relief for cars which were designed for people who had lost the use of their hands, arms or legs but, because of the wording, the Revenue Commissioners decided it did not apply to people who had lost limbs in more than one of the categories.
We must take a generous view based on common sense and this view must be inculcated in those who make decisions. Regulatory assessment of what people need cannot be determined by budgetary considerations but by the objective facts. Then it is the job of society to ensure that our old people are supported and sustained in quality care. Families can then be assured their expectation of quality care is not something they must suppress.
I do not want to prejudge the outcome of the investigation. However, looking at the situation from the outside, it is clear that good, caring children had considerable reservations, but did not know there was somewhere to go with their complaints. They could have taken their parents or elderly relatives from these premises, but there was no place else to put them. As a person with a mother who is old and feeble, I cannot imagine a worse dilemma than to have a much loved relative in an institution where the standard of care is so poor that one must complain. In such a case, one would inevitably be told that it was fine to take him or her away as there were ten or more people waiting for a place. The real function of the State in this area is to end this dilemma. I hope we achieve this as a result of the investigation.
There is no cheap solution to the dilemma. We must accept that as with primary education, maternity hospitals and other areas, the provision of hospital or institutionally-based care for people in the last years of their lives is part of what we must pay to be a civilised society. This can no longer be regarded as an exception or an add-on. Let us suppose, for example, we had a doubling of our birth rate. Would we suddenly announce we could not afford the extra maternity facilities this demanded or would we say it is something for which we must pay? I know we would say we must pay although I am not entirely sure I know what the current Minister would say as her views on public health care provision are far from clear. She has, with some justification, been accused of a kind of subterfuge in the privatisation of these services. Nevertheless, the majority of people in society would say the solution is better, namely, more extensive public provision when there is a need.
It is as easy to look at the care of old people as at maternity care. Why should old people be seen to be any more of a burden than a new baby? The language used by commentators, economists in particular, is inimical to the view that an old person in his or her last years is as precious to society as a newborn baby. There is an horrendous backward step for some economic commentators to suggest that a baby as a potentially productive unit in society must be nurtured, but an elderly person is a post-productive unit of society and is, therefore, a burden.
I hope the investigation will identify a process which will lead us to a situation where care for older people in institutions becomes part of a smooth, seamless transition through life, where maternity care is the beginning, followed by proper school and health services and proper adult health screening. There should be a smooth transition from phase to phase of life and no phase should be identified as a burden or become such a burden for caring relatives that it makes them afraid or discourages them from expecting the highest possible standards.
I thank all the Senators who have contributed. In particular, I wish to acknowledge what Senators Terry and Glynn said about the late Kate Walsh. Wonderful tributes were paid to her yesterday and it is a pity she was not here to hear them. She was a very special person. Many people have portfolios, but her only portfolio was friendship. She had friends everywhere and was a much loved and well respected person. She had a great grá for many people in this House and I never heard her say a bad word about anybody here.
I visited her a lot during her illness, most recently last Sunday night. However, little did I know she would be dead on Tuesday morning. We were all shocked to hear it because it was not her cancer that killed her but something different. The pity is she was not here to hear the tributes because she would have had a good laugh. Right up to the end, she did not lose her sense of humour and had many funny stories to tell over the past few weeks in St. Vincent's Hospital in Dublin.
On the questions raised, following the passing of the order here and in the Dáil today, the investigation will be established to be conducted by a sole member, Mr. Derry O'Donovan SC, over a 12-month period, with provision for an interim report. We estimate the inquiry will cost approximately €2 million. The matter of the transfer of patients from St. Ita's will be a matter for the chairman who will have the power to consider any issues relating to transfers of patients.
I met some family members of former residents of Leas Cross and must say that after hearing their stories I would be very bitter if it had been one of my parents involved. To take up a point made by Senator Ryan, it is a fact that many people, including those who are well informed, do not always realise that bed sores could be the result of neglect. Sometimes they feel these are a natural consequence of old age. Many relatives of patients feel guilty or think they should have noticed more. The least we can do is to ensure we learn from the experience. In particular, we must learn from the experience of how the authorities responded to the complaints made. Much of Mr. O'Donovan's inquiry will investigate this area. Hopefully, the authorities, those with an inspection function and those involved with complaints, will learn lessons from the experience in Leas Cross.
As Senators know, up to now there has been an inspection process only for private nursing homes. However, the Government has decided the new social services inspectorate process under HIQA will inspect all nursing homes in the public and private sector, which is appropriate. Senator Glynn mentioned somebody going to visit an aunt who had been dead 16 years after the announcement of the repayment scheme. Unfortunately, we hear such stories, but such people are in the minority. I have heard a similar story on several occasions when visiting residences for older people. Nurses have said to me they did not know some patients had relatives because they had never seen them. This development is infuriating and annoying. There is no legislation that can insist people must visit their relatives, but visiting the elderly is, I hope, one of the wider values in our society.
I share the view expressed by Deputy Ryan and do not just see young people as productive and older people as a drain on the State. I was listening to a radio programme last Sunday when driving from Cork to Offaly and heard a comment made that we were investing moneys in properties overseas that should be going into the health system. The implication was that the Government was investing in properties overseas. This was one of the few occasions I was tempted to phone the programme and point out that it was citizens rather than the Government who were investing in overseas properties, but I did not do so. I hate the value system that talks like this, particularly with regard to who is or is not productive. Although I support enterprise in society and the reward of enterprise and initiative, I am equally strong about the importance of a value system in our society through which we can support each other and the importance of community. I will not be provoked into giving my views on the public system except to say I believe access to State-funded services should be available to everybody on the basis of medical need and no other basis. We are far from that ideal. In all public hospitals a minimum of 20% of beds is ring-fenced for private patients and a consultant receives a private fee for any private patient who goes into the public hospital except through the accident and emergency department. The same applies to the pathologists and radiologists if the person is in the accident and emergency department. I have problems with that when taxpayers are funding the system. We are trying to ensure that what the taxpayers fund is available only on the basis of medical need. Who invests the money and how are minor issues, what matters is the standard of care. I am strongly of the view that all consultants must be available to all patients not just a few. That is the basis for some of our decisions but I refuse to be drawn into that debate.
The current standards are the 1993 standards, which are deficient. We have learnt a great deal since then. The draft standards are available for discussion. We held a good conference a couple of weeks ago to discuss them with many stakeholders, on foot of which they are being revised. The Health Information and Equality Authority, which becomes effective after the introduction of the regulations on 11 May will be responsible for all these issues, particularly for enforcing them.
I accept Senator Henry's point that we are great at inquiring and fact-finding but often do not draw the conclusions and change practice. There is no point in holding this inquiry at the not inconsiderable cost of €2 million unless we put into effect any conclusions reached. Relative to a budget of €15 billion the sum is not much but it could achieve much in other areas. The standards will be phased in over three years, to deal with physical and environmental issues, rather than care. This will take time and we must be reasonable and proportionate in our approach to this change. I am delighted with the support for the establishment of the inquiry. I wish it well and look forward to its conclusion and report within 12 months.