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New behaviour protocol request

A report in relation to care at Cappahard Lodge, Ennis of the late Gerard Finn has been published. Reporting By Dan Danaher.

CLARE Mental Health Services (CMHS) has been requested to develop a new protocol for dealing with challenging behaviour expressed by families and complainants, with particular emphasis on training in mediation skills for designated staff in Cappahard Lodge, Ennis and other facilities.
That’s one of the 37 recommendations made in the latest review of the care provided and complaints made in relation to Gerard Finn, Kilrush, while he was a patient at Cappahard Lodge.
The review team commissioned by the HSE has also recommended the function of Cappahard Lodge should be addressed as a matter of urgency, to establish a clear vision and purpose for the unit, addressing issues such as case mix and whether it should only accommodate patients with dementia.
It called for a review of the management in Cappahard Lodge as a matter of urgency, resulting in, ideally, one individual in charge of all issues relating to day-to-day care.
It stated CMHS should develop specific drug and prescribing policies for patients in Cappahard and other facilities, including clear guidance for staff on the writing of prescriptions to include the indication, frequency and in the case of certain prescriptions, minimal and maximum time interval between doses and the maximum dose in any 24-hour period.
“There is clear guidance from the Medical Council to cover the issues surrounding requests for second opinions. The clinical director should bring this guidance to the attention of consultant psychiatrist X in particular and to e ach member of the clinical team, in conjunction with the recommendation in relation to next-of-kin, which deals with capacity.
“In addition, the clinical director should pursue any training issues which the implementation of this recommendation might reveal.
“CMHS should develop, implement and audit a written guideline for the disclosure of relevant information to family members including information following adverse incidents.
“All injuries/unusual markings including bruising should be clearly and accurately documented in clinical records. In addition injuries/unusual markings should be investigated to ensure that an explanation can be established.
“CMHS should develop, implement and audit written guidelines in relation to the use of restraint as part of an overall Falls Prevention Policy.
“Recommendations made in the Lyons Report dealing with the issue of assessment and care planning completed in October 2008 that have not been implemented to date should be done so as a matter of priority,” the report stated.
In addition to recommending family members of patients should be consulted with and involved in the care planning process, it proposed CMHS should consider introducing a mediator where complex complaints are being handled to avoid a situation where both parties have reached a point where they are no longer communicating effectively with each other.
It requested the director of advocacy should undertake an audit of complaints made against Clare Mental Health Services since the introduction of the new statutory complaints process in January 2007 to ensure that the established process is operating as intended.

Patient’s wife praises husband’s care at facility
THE latest report into the standard of care provided to the late Gerard Finn at Cappahard Lodge vindicates the mental health facility, according to his wife, Anne.
In an exclusive interview with The Clare Champion, Anne Finn said she never felt that her late husband was the subject of abuse.
Gerard Finn was born in Pella Road, Kilrush and had a relationship with Anne in their younger days for about 18 months until they went their separate ways.
Having been re-united in 1979, Anne recalled they were together for 28 years and got married in 2001. She said Ger was diagnosed with Alzheimer’s in 2003, was admitted to Cappahard Lodge in December 2005 and died in June 2007.
“I was never worried about Cappahard Lodge coming out in the wrong in this report. I was over visiting my husband three or four times a week between 11am and 2.30pm and I saw everything that was going on. I found no instances of abuse.
“Ger’s sisters also visited him regularly and none of us could find anything wrong. I have put down a hard few years.
“I have had people meeting me in the street asking me how could you have put Ger in there,” she said.
“I would never do anything to Ger that wouldn’t be in his interest and his sisters would tell you that.
“Lies were told which I don’t want to go into. As far as I am concerned, this report has cleared up this issue.
“I am sorry for what the nurses had to go through. I have been interviewed together with my daughter, Catherine, by Dr Lyons and Mr Brophy for the last two investigations,” she said.
Acknowledging that she does not “get on” with two of her husband’s daughters, Mrs Finn stressed she does not want to engage in any further controversy regarding the care provided to her husband.
She said that she cared for Ger at home for about 18 months with the help of her daughter Catherine, who gave up her job at the time to help.
“I would have loved to have been able to have kept Ger at home even longer but eventually I had to put him into Cappahard Lodge.
“He was in Cappahard Lodge for respite for a few times and he knew the nurses and doctors very well.
“Alzheimer’s is a terrible condition and I wasn’t able to look after him any longer. I am only four foot 10 inches and he was about 14 stone at one stage. It became difficult to dress him and do things for him because of his condition.
“Sometimes when Catherine took him for a walk he would fall over.
“We got a wheelchair and Catherine would take him for a walk out to Cappa to give me a break.
“He got bruises when he fell over at home. Sometimes when you would take him for a walk he would forget to lift his legs, that’s why we had to get a wheelchair.
“If his sisters felt there was anything out of place in relation to his care, they would have come after me.
“Overall, he was very happy until the end. It was very hard watching him get progressively worse,” she said.
In a statement issued to The Clare Champion in July 2007 before the latest report was commissioned, Gerard’s sister, Mary O’Brien from London, who visited him in Cappahard Lodge, confirmed that she and other family members had nothing but admiration for the staff and the doctors.
“The hard work they put in to care for my brother was unsurpassed. Gerard had Alzheimer’s, which is a very nasty degenerative disease that causes a person to lose mind and dignity.
“However, I can safely say my brother died with his dignity due to the nursing staff that cared for him before he passed away.
“I would not want these wonderful people to think that I, or his wife and the rest of our family would be as callous to have an investigation brought on them,” she said.

HSE to consider report’s recommendations
THE Mid-West Health Service Executive (HSE) has pledged to consider all 37 recommendations made in the review.
In a statement issued to The Clare Champion, the HSE confirmed all of the recommendations would be considered in conjunction with the proposals contained in an earlier report of an independent review of policies and procedures in Cappahard Lodge, led by Professor Donald Lyons in 2008.
The HSE predicted this would create a learning process, which would enhance the quality and safety of the care delivered in Ennis mental health facility.
The authority does not routinely publish details of individual complaints or complaint reviews, due to the private and personal nature of the information concerned.
However, in response to various statements about a complaint review relating to Cappahard Lodge, the authority noted the facts giving rise to this review occurred between late 2005 and June 2007.
These formed the subject matter of an ongoing series of complaints made by some relatives of a client, referred to in the report as Patient X to preserve their privacy.
However, the HSE also pointed out that other relatives of the patient took a different view to the complainants and publicly defended the care and treatment given to the patient at Cappahard Lodge.
Features from the report include conclusions by the review team to the effect that Patient X needed the care of a specialist and that the placement in Cappahard Lodge was appropriate
The HSE stated the report noted there was no evidence that drugs were used to sedate or control Patient X.
“There was no evidence to conclude that bruising incidents complained of were untoward or caused by poor care and treatment
“There was no evidence to suggest that the restraint used on Patient X exceeded the parameters outlined in the documented care plan.
“Regrettably, there was a critical breakdown in relationships with the complainants. Marked divergences in the viewpoints adopted and differences between family members did not allow for the recognition or acknowledgement of any common ground,” the HSE stated.
The review team was able to identify areas of service improvement and made recommendations which will, when implemented, leading to improved quality and safety systems for staff and patients in Cappahard Lodge.
These covered the areas of capacity, consent, next of kin, medication, communications, family involvement, advocacy and complaint management.

Staff complaint to An Bord Altranais
The alleged actions of a lecturer in nursing in University College Dublin during a visit to a Clare mental health facility were the subject of a complaint to An Bord Altranais Nursing Board by staff members.
According to the report, nursing staff at Cappahard Lodge made a complaint in relation to the actions of this qualified nurse, who acted as an advocate for a relative of the deceased during a visit on November 14, 2006.
In the report, a staff member stated that it was agreed to re-examine Patient X (Mr Finn) who had been reviewed by a GP an hour previously.
“It was documented that his chest was clear and his observations were normal. He was drowsy but tolerating fluid. The GP made a decision to prescribe an antibiotic as a precaution in view of his cough.
“In this subsequent re-examination it is recorded that the GP documented that Patient X’s condition had improved, he was alert and he was drinking and he did not appear to be in distress.
“The GP had documented that on the basis of his examination, there was no evidence of any serious problem and that it was inappropriate to transfer Patient X to Ennis Hospital.
“The GP spoke to Ms 1 and Ms 2 and reassured them. The plan of care was documented as ‘continue antibiotic and review if necessary’.
“There are significant differences between this account of events and that furnished by Ms 3 (nurse) to the review team.
“Ms 3’s account indicates that staff members met Ms 2 with an aggressive manner. Patient X did appear unwell. He was restrained in a Buxton chair. His cheeks were sunken, his eyes were glazed, his tongue was furred and lips were chapped.
“Ms 2 was very upset by his condition and Ms 2 rang Mr S, who advised her to call the Gardaí.
“She did not make any statement that it was her clinical judgement that Patient X had pneumonia. She did not make any statement that the earlier findings of the GP should be negated.
“She did not make any statement that their code of practice required the findings of the GP should be negated,” the report stated.
The review noted that the nurse said it would reassure Ms 2 if Patient X was reviewed at Ennis Hospital and did not discuss any contentious matters in front of any residents.
It stated she insisted at all times she acted with the sole motivation of defusing a contentious and rapidly escalating situation.
An Bord Altranais wrote to Ms 3 and advised her that a report about her visit was being considered by its Fitness to Practice Committee as an application for an inquiry.
Ms 3 responded to the board, setting out a very robust defence of her actions. The report presented by staff and her response evidenced the considerable conflict in the versions of the events on the day.
The Fitness to Practice Committee decided there was not sufficient cause to warrant the holding of an inquiry into the fitness of Ms 3 to practice nursing and recommended that no further action should be taken, which was accepted by the board.
The review team wasn’t privy to the internal deliberations of the Fitness to Practice Committee and in the absence of any other independent third-party corroborative evidence, it wasn’t possible for them to make any determination in relation to this aspect of the complaint about her treatment.

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