Basic errors included failure to properly monitor high-risk case

Investigators found four contributory factors which had an effect on the tragic outcome for Tristan Neiland. These systemic failures at Angels Quest Respite, under St John of God were:

1. Written instructions given by the family for Tristan’s care were not followed.

Mrs Neiland supplied staff with an Oxygen Saturation Monitor (SATS monitor), which measures oxygen levels, and explained in writing how and when to use it. This was not used during the weekend, nor during five previous stays in October and November 2012.

There is no record of any discussion around deciding not to use it. Tristan had used the monitor since he was three months old but the report finds that staff may not have understood its purpose.

There was also a lack of communication between various staff as to the use of the monitor, with at least one staff member saying they were unaware of it.

2. Risk-assessment was not carried out, no risk plan was devised in advance of taking Tristan into the centre.

The report notes that Tristan had used the centre as a day visitor but staff appear not to have understood that night-time care needed to be more rigorous.

The report also states, regarding a risk-assessment document: ‘The weight of evidence suggests that this document was written after the night of January 5, 2013.’

In any case, the document also ‘seriously underestimates’ the risks posed by Tristan’s illnesses.

Investigators found it was not clear who was in charge of Tristan as a number of employees were in contact with the family regarding instructions, instead of just one key worker. This was a management failing.

3. Observation and monitoring were inadequate on that night. It was not noticed that the boy’s condition was deteriorating.

Tristan was not checked during a crucial 88-minute period, in spite of staff – including managers – saying that children were checked at various intervals of between 10 and 15 minutes.

Despite Tristan’s risk level, his scheduled monitoring was the same as for the other patients in the centre, but that night he was not even monitored in a general way, with long gaps left between observations. The report states that nursing notes for that night were ‘unspecific, vague and lacking in conciseness’.

Baby monitors which only record sound were used, inappropriate for a child with Tristan’s conditions, which gave rise to silent symptoms. Five monitors were in use on the same frequency, which causes static and interference. The baby monitor for Tristan was in the corridor outside his bedroom.

4. Management of risk by senior staff was inadequate; no system was in place to analyse risks or adverse events. It appears that no clinical incident form was filed for the night he died.

An information sheet given to parents refers to a ‘Respite and Referrals Committee’ but when investigators requested minutes or notes of how care for Tristan was decided upon, they were told the committee did not even exist. Investigators felt that this information was misleading.

At a managerial level, there was ineffective evaluation of Tristan’s risk status and a lack of managerial supervision. The report notes that a staff member had previously raised concerns about the number of rostered staff for that weekend in light of the children’s needs.