Galway people worked hard to set up the hospice scrutinised in yesterday's damning report, writes Eithne Donnellan, Health Correspondent
Like many other hospices across the State, Galway Hospice was built entirely on voluntary contributions.
The building was completed in 1993 after years of fund-raising, which included weekly draws to which thousands contributed £1 a week and an arrangement whereby farmers in the county agreed to a levy on each beast they sold at local marts.
When the hospice then accepted its first in-patients in 1997, following the receipt of State aid through the Western Health Board to fund running costs, the people of Galway felt justifiably proud.
Things seemed on the surface to be running smoothly at the 12-bed unit until in early 2002 the home care service was suspended temporarily to allow additional staff training take place.
Then last May real trouble began when the health board's sole palliative care consultant, Dr Dympna Waldron, who also worked at the hospice, raised concerns about what she believed were 17 "serious life-threatening errors" in the administration of drugs to hospice patients.
As a result she stopped referring patients to it, and since then the hospice has been closed to new admissions. This situation has angered the people of Galway city and county who toiled for years to establish the hospice.
Two organisations, the Galway Hospice Association and Glór an Phobail, were formed to campaign for the reopening of the unit. Thousands of signatures were collected on the streets of Galway and presented to the Minister for Health, Mr Martin, and hundreds marched in protest through Galway just before Christmas to highlight the continued closure of the facility.
When Dr Waldron's concerns came to the attention of the independent board of directors which runs the hospice, they initiated an independent inquiry. It is their report which was published yesterday.
It catalogues a litany of errors in the administration of drugs to patients at the hospice between January 2002 and May 2003. In four cases emergency intervention was necessary in order to sustain life, the report said. Patients in these instances had to be resuscitated.
While the report points out that these errors did not kill any patient, they are certainly significant mistakes. Examples include the fact that a nurse selected 100 mg tablets instead of 300 mg ones for one patient and gave them to a relative to administer.
The relative noticed the error before the drugs (Gabapentin) were given. This, the report said, was in breach of hospice policy which indicated a nurse should remain in the room while the patient was taking his or her medication.
In another incident, a nurse dispensed a 600 mcg Fentanyl lozenge for a patient when a 200 mcg one had been prescribed.
The nurse realised her error before the patient took it and subsequently "asked a colleague to sign the controlled drugs register retrospectively, although the colleague had not checked the drug at the time. "The colleague refused."
In further incidents, nursing staff withheld one day's medication from a patient without telling the doctor and in another incident a patient prescribed a drug was not given it and, again, a doctor was not informed.
Nurses weren't the only ones at whom fingers were pointed, however. Doctors too were found wanting. In two of the most serious incidents, patients received 10 and 15 times the amount of medication they should have received. This was due to prescribing errors by doctors. When the 10-fold overdose was uncovered by nurses, it took them 45 minutes to call a doctor. Both patients had to be resuscitated.
In a number of cases the errors were uncovered by a pharmacist, who in one case noticed that a patient was being given Warfarin, an anti-clotting agent, every day instead of on alternate days as prescribed.
The investigation found "little or no evidence of audit, evaluation or risk assessment" and evidence of poor and tense relationships between members of interdisciplinary team members, "resulting in less than optimal work relationships".
The health board is conducting a separate investigation into allegations of bullying against Dr Waldron.
It is understood Dr Waldron is denying the allegations.
Overall, what is clear from the detailed investigation which has been published is that practices and procedures need to be put in place at the hospice to ensure no further avoidable errors occur before the facility is reopened to other, albeit terminally ill, patients.
Furthermore, the findings show Dr Waldron was right to raise concerns about practices at the hospice. Otherwise, we might never have known what was going on.