Long campaign for truth is another sorry saga for HSE

THE long search for answers about the horrific death suffered by pensioner Jimmy Grogan reads like a familiar sorry saga endured by too many families.

The relentless campaign by his partner Muriel Kiely for a full investigation into why he was transferred to a HSE-run nursing home a decade ago, which did not have the facilities to provide him with vital oxygen, has echoes of similar struggles by loved ones.

It’s now a decade since Mr Grogan, who was terminally-ill when discharged from Ennis Hospital, died from a lack of oxygen within 30 minutes.

The case has been the subject of a number of reviews but there is some consolation for his family in a new HSE-commissioned independent report.

One of its most telling conclusions, which will ring true for others who have battled with health service red tape, is that an investigation into his death should have been carried out automatically.

Why was he discharged from hospital in such a fragile state?

It was clear he needed 15 litres of oxygen to survive but the nursing home Regina House in Kilrush which received him had no advance notice of this.

The independent report said an examination of this catastrophic incident should not have relied on a complaint being made by a relative. A full systems analysis should have followed automatically.

A suitable team should be found to conduct this kind of probe in a timely manner.

Instead, the family just received a written response from the hospital to the initial complaint.

After more pressure another review was conducted, but it was not until 2010 that a systems analysis was ordered, dragging out for another three years.

This latest independent report found that the lack of the necessary oxygen equipment at the nursing home made Mr Grogan’s death “inevitable”.

This is a stark admission. The director general of the HSE, Tony O’Brien, said it accepts responsibility for the events that led to his death and has apologised to Ms Kiely.

But there have been too many similar acts of contrition by the HSE.

As ever, in the wake of these reports, there is a list of changes which the HSE says it has made to avoid another case.

There are new guidelines on oxygen therapy, a policy of open disclosure when there is an adverse event as well as a guide on the discharge and transfer of patients from hospital.

However, long-time patient advocate Jim Reilly yesterday again highlighted the need for a national patient safety agency which has statutory powers.

It should not take a decade to get answers, he warned.

The last government promised this patient safety office and instead of opting for one with legal powers it installed an agency within the Department of Health.

The Health Information and Quality Authority (Hiqa) has a patient safety brief but its remit is limited.

Too often patients and families are at the mercy of the HSE’s own internal systems of investigation.

In his letter to Ms Kiely, Mr O’Brien said the HSE has made considerable improvements in its processes in the last 10 years.

They were too late for Mr Grogan but he hoped the tenacity shown by Ms Kiely would help make the healthcare system safer for future generations.

The hope is that the HSE has learned lessons.

But it is time for the Government to give the public a proper patient safety agency or else extend the powers of Hiqa to avoid other families having to endure this kind of suffering.