An investigation into a Covid-19 outbreak that killed 22 residents in a nursing home found “significant concerns” with the initial response and management of the spike in cases in the Health Service Executive (HSE) facility.
St Mary’s nursing home in Phoenix Park was one of the worst hit in the first wave of the pandemic, with 60 per cent of its 146 residents contracting the virus.
The HSE commissioned an independent report on claims made by a staff member in May 2020 about shortcomings in the response to the outbreak.
The report, published on Thursday, made a number of criticisms over the response to the virus in late March and April 2020.
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The report found a strong sense of direction about the need to follow guidelines was “lacking”, particularly when it came to the need to isolate residents.
The nursing home “struggled in the early days of the outbreak to come to grips with what was occurring”, it said.
While it noted HSE area managers appeared to “tirelessly” try to source Personal Protective Equipment (PPE) for the nursing home, it said it was “clear more could and should have been done”.
The facility had been dealing with “high levels of staff” out sick with the virus, as well as “changing advice”.
The investigation criticised wider delays in the testing system which were outside the control of the nursing home but allowed time “for the virus to circulate unchecked”.
The investigation was undertaken by Gerry Rooney, managing director of mediators Acrux Consulting, Dr Paula Hickey and Irene O’Hanlon.
Efforts to protect residents and staff in the home were “hampered by a number of factors”, such as a national shortage of PPE and high numbers of staff out sick.
The report found St Mary’s did not isolate residents with symptoms in accordance with guidelines for several days in early April.
The investigation said failures to categorise residents into infected, symptomatic or asymptomatic, amounted to “poor practice”. It added that this “probably contributed to poor management of the outbreak and may have put some residents at risk”.
The report said management “failed to allay the concerns” that were raised over visitor access to the home, before a ban on visits was introduced.
It also said allegations there was a failure to enforce social distancing guidelines in the facility were “well founded”.
Given how vulnerable residents were, breaches of social distancing “should not have been tolerated”, it said.
The report also investigated allegations there was an “overly stringent” management of PPE. A review of inventory at the nursing home from the time shows “challenges” existed, but management responded “reasonably” given nationwide shortages.
However, it did criticise management’s communication with front line staff over PPE supplies as “suboptimal”.
The report said it was not until April 17th 2020 that the National Public Health Emergency Team (Nphet) endorsed testing of all nursing home staff. It said in the weeks before this staff in St Mary’s “were severely disadvantaged by the unavailability” of testing and results.
In the early stage of the outbreak nurses were requesting medical reviews for residents with symptoms, but these were initially attributed “to other conditions” than Covid-19.
A review of records show it was “probable” that some medical staff were applying “limited criteria” to identify the virus, which resulted in delays diagnosing people.
The investigation said daily temperature checks of residents were not taking place as required due to “low staffing levels”.
The management team “lacked a comprehensive direction on what issues needed to be prioritised, with an immediate focus on sourcing PPE and swabbing/testing of residents”.
The “deteriorating situation” in the care home was “not clearly communicated” to HSE management in the early days of the outbreak.
The report said St Mary’s had maintained it provided “appropriate care for residents”, while acknowledging the outbreak was a “particularly challenging time” for staff, residents and families.
Staff told the investigators that they felt they “did their best at the time” in a situation where advice and knowledge of the virus was regularly changing.
The investigation noted the death rate in the home was “not significantly different to the national average” in nursing homes.
The report was commissioned after a protected disclosure was made to the HSE in May 2020 by Margo Hannon, a healthcare assistant at St Mary’s, about alleged shortcomings in the facility.
The investigation said it was clear the unaddressed concerns of Ms Hannon “became a problem in itself”.
“This lack of clarity in preparing for and responding to Covid-19 is the essence of many of the concerns we have considered and upheld within this investigation,” it said.
The 36-page report published on Thursday was an executive summary of a more extensive report, which the HSE has said it will not be publishing.
