An investigation into over 20 Covid-19 related deaths at a HSE-run nursing home in Dublin during the first wave of the pandemic in 2020 has outlined "significant concerns" regarding the management of preparations and the initial response to the outbreak of the virus at St Mary's Hospital in Phoenix Park.
The executive summary of the investigation into allegations raised by a protected disclosure follows a two-year investigation by Acrux Consultancy, which was commissioned by the HSE to investigate the claims of a whistleblower.
As part of the examination of the claims, the investigation team held 47 meetings with various parties.
It has concluded that a gap occurred with the engagement between leadership and those on the ground.
"What is compelling is that all of the managers we met maintained they did their best, that they were not left wanting in responding to what occurred in front of them, and that they made decisions based on the right reasons with the care of the residents to the fore.
"We do not doubt that sincerity, nor the genuine efforts made by management in seeking to manage what had emerged.
"We got a sense that they were swamped by what occurred at the time of the outbreak and in the immediate weeks thereafter."
However, what appeared to be lacking, according to the report, was "a strong sense of direction" about the need to adhere to the guidelines, and the provision of guidance and reassurance to staff.
It said that while the future may have been unknown, immediate actions needed to be coordinated and followed in a crisis like the pandemic.
"That sense of direction was not evident," according to the report.
Acrux said the team was advised that decision making could have been more streamlined.
"The investigation observed in the evidence that activities were fragmented and focused on resolving the external challenges (such as PPE and testing) rather than providing leadership and direction to frontline care staff," it said.
The review team upheld issues raised under five of the 12 themes in the open disclosure, and did not uphold issues under seven of these themes.
The HSE has fully accepted that there were a number of issues identified in the report that put residents at further risk of Covid-19 infection at that time.
The HSE has acknowledged the important role of the discloser in highlighting issues and says it remains committed to continually learning and reviewing to support making its services safer.
Over the course of two years, the Acrux team met whistleblower Margo Hannon who was a healthcare assistant in the nursing home during the outbreak.
It says it "has no doubt" to the genuineness of the concerns raised by the discloser.
It also met with the family of residents who died, and staff of the hospital.
The investigation focused on what occurred over a three-week period during the first wave of Covid-19 - from late March 2020 and during the early weeks of April 2020.
During this period, 22 residents had sadly passed away due to Covid-19.
The report points out that the investigation is not focused on establishing wrongdoing by any individual party or persons.
In accordance with its terms of reference the investigation set out to review the concerns raised and to determine whether the disclosed wrongdoings have/or are occurring and to assist the HSE to ensure any improvement, learning or other actions can be taken in response to each aspect of the protected disclosure found to have been occurred, be occurring or likely to occur in the future.
In a statement issued today it said that given the requirement to protect the identity of residents, families and staff, the HSE is precluded from publishing the full report from the investigation team.
However, it says the review team has provided a comprehensive executive summary, which fully represents the issues raised in the full report.
HSE National Director for Community Operations Yvonne O'Neill offered deepest sympathies to the families of those residents who passed away in The Phoenix Park Community Nursing Unit (otherwise known as St Mary's Hospital) during this period.
"We have been in contact with each of the families of those residents who passed away during this time and have met with those families who wished to meet us. They are being provided with a copy of the executive summary report and we remain available to answer any further questions they may have.
"We have also provided details in relation to this report to our current residents and their families, to our staff, and to the solicitor representing the individual who made the original disclosure."
