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The patient died in 2015 following what was alleged was a "rapid decline" in her health at the hospital for elderly people, amid allegations of severe dehydration and malnutrition. (Stock image) Alamy Stock Photo
Patient Care

Report finds senior HSE official conducted 'seriously flawed' and 'biased' investigation

The report arose out of serious concerns after an elderly patient suffered a dramatic decline in her health before dying in hospital.

AN INTERNAL PRELIMINARY report found that a HSE regional manager of elderly care conducted a “seriously flawed” and “biased” investigation into a staff dispute over the care of a patient.

The investigation, which was commissioned by the HSE following a formal complaint by a healthcare assistant alleging major issues around the patient’s care, found that the director ”breached HSE policy” in running the investigation in her own hospital.

It is one of two investigations the HSE formed to examine the incident. One was to focus on allegations surrounding the patient’s care and the other honed in on the dispute among the facility’s staff and management. 

The staff dispute arose after a number of nurses and healthcare assistants wrongly believed their colleague had encouraged the patient’s family to submit a formal complaint over how the patient, who was aged in her 90s, was being looked after. 

However, the investigation remains only half complete as the HSE has yet to finalise its own actions and outcomes, including any sanctions, from the investigation – despite receiving the investigator’s preliminary findings last October.

The patient died in 2015 following what was alleged was a “rapid decline” in her health at the hospital for elderly people, amid allegations of severe dehydration and malnutrition.

In the preliminary findings by an external HR firm, investigators noted that the senior manager had focused on issues involving the healthcare assistant (HCA) that were “not in her [2015] letter of grievance”. 

While the HCA had raised allegations that she had been “singled out” by fellow staff following the family’s complaint, investigators found that the regional manager had focused her investigation on a recent change in the hospital’s staff rota.

In her testimony, the HCA had claimed that the incorrect focus on rotation was an attempt to “confuse” issues around the dispute. 

This HCA became a whistleblower when she submitted a protected disclosure in May 2018 about the elderly patient’s care and staff issues arising from the controversy.

The complaint referenced medical notes and the patient’s decline and death over the final weeks of 2015. 

However, the HSE separated the protected disclosure and the staff disputes into two separate strands to be investigated. 


The HSE formed a review into the patient’s care but the HCA has yet to be interviewed about her claims, five years on from making the protected disclosure in May 2018.

The second investigation, focusing on the staff dispute, has now found that there was “sufficient evidence and testimony” to find that the HCA was subject to “unfair treatment from her colleagues” and “some members of her management structure” arising from the controversy.

It added that the issue was “created” following a “minor positive comment” contained in a “greater complaint” made by a patient’s family about the HCA, who had interactions with the elderly woman. 

The HCA said she was confronted by a number of staff in the aftermath of the family’s complaint, including by one who was alleged to have been “screaming and banging her chest” over the matter. This interaction was witnessed by other staff who spoke to investigators.

The fallout of the incident and “the lack of support” the HCA received from her ward manager was described in the report as a “major contributory factor as to why this investigation team are investigating the matter some seven years later in 2022″.

According to the preliminary findings by the investigation team, the HCA said that she had intended to proceed with a case at the Workplace Relations Commission in 2020.

However, during a meeting last year, she told investigators that she was concerned about how her protected disclosure would be handled as she alleged the regional director of elderly care, despite being under investigation, was sitting on the same panel receiving internal complaints as the authorised person handling the HCA’s protected disclosure. 

She then withdrew the WRC case.

Protected disclosure

In a protected disclosure submitted in May 2018, the HCA alleged the patient, a woman aged in her early 90s, saw her condition rapidly decline over a period of approximately five weeks.

The disclosure came following a complaint made by the patient’s family. 

Medical notes taken at the time, seen by The Journal, recorded the woman being severely dehydrated and in an emaciated condition at the end of this period.

She was brought to hospital shortly after and died. 

According to letter sent by the HSE to the whistleblower, it said she could not be kept informed of updates into the investigation arising from her protected disclosure due to her not being a “next of kin” to the deceased elderly patient.

2015 staff complaint

As part of meetings held last year with an external HR firm contracted by the HSE to investigate the issue, a total of seven separate staff and members of management were interviewed over the dispute among the healthcare professionals.

The meetings were conducted throughout April and June last year.

In her interview, the HCA alleged that at handovers in the hospitals many staff would “laugh at and mock patient complaints” which had been received during the shift.

She said that the complaint by the patient’s family, which was not described in the report, “was handed around for all to see and widely discussed” by staff.

One manager interviewed contended that the staff were “somewhat nonplussed” by it, that they took it on board and the manger then carried out an action plan to address the concerns.

The same manager confirmed that she would not have been at every handover and she did not witness any of the behaviour described by the HCA, but could not vouch for what happened when she was not on duty.

The HCA alleged that she was met with “extremely aggressive” behaviour by different staff members following the complaint, further claiming that there was shouting and screaming directed at her.

In its findings, the investigation team found that on the “balance of probability”, the incident was more likely than not to have occurred as set out in the HCA’s complaint and in her interview.

Regarding the regional manager of elderly care’s initial examination of the dispute following the patient’s family’s complaint, the investigation team said it appeared “flawed in terms of process and procedure and determination of findings”.

Regional manager

The team upheld a series of complaints made by the HCA about the regional manager.

Citing the testimony provided by the senior figure, the investigation team said “she was biased in her views when conducting” her inquiry.

The conclusion to the regional manager’s findings included a statement declaring that “there was no defamation of [the HCA's] character by the family” of the elderly patient – but the investigation team found that “at no stage” was a complaint of defamation ever made by the HCA.

Instead of addressing the complaint around how staff had allegedly treated the HCA, the report found that the regional manager had formed the view that a recent rotation of staff was at the nub of the HCA’s unhappiness, and that she believed the HCA was “difficult to manage”.

“Because of this bias, she strayed from investigating the actual complaint made,” the report concluded.

“In any case, it was not for the manager of the full care of the elderly services . . . to investigate, in the first instance, a complaint at ward level in one of the hospitals for which she was responsible for.” 

As regards an allegation by the HCA accusing the regional manager of “deliberately” allowing false accusations be made against her by fellow staff, the report concluded:

“Whereas there is evidence that the investigation carried out by [the regional manager] was seriously flawed and, at times appeared to be influenced by undue bias, the Investigation Team cannot find that this was done deliberately or maliciously.

‘Smear campaign’ 

A further claim allegedly made about the HCA by some staff was that she had asked the patient’s family to make the original complaint in 2015, which the investigation found was unfounded. Despite this, the report said “it does not appear that [the regional manager] did anything to correct the stated contrary views” of some other staff.

A final claim by the HCA was that all managers, including the regional manager of elderly services, had participated in a “charade and smear campaign” against her. On this, the Investigation Team said:

“In finding that this is not upheld, [we] do find that the process adopted was ill fated and seriously flawed.”

The HCA did not work for the Executive following the incident in 2015. 

The regional manager has since retired. 

A spokesperson for the HSE declined to comment when contacted.

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