The National Incident Management Agency was asked to examine the circumstances of the incident in line with governance arrangements on the night of 3 April 2020.
It was at the height of the first lockdown and Covid restrictions were in place. A healthcare assistant who was due on duty that night had called in sick.
On the night of 2 April into 3 April 2020, there was no overall manager (CNM I) in charge, which was normal practice in the nursing home at the time.
There were two staff members on duty in the unit where Emily resided: healthcare assistant Mr Z and Staff Nurse 1.
Usually there would be an additional healthcare assistant on duty overnight whose role was to give additional support where it may be needed across the nursing home.
However, this HCA was not on duty that evening as they had reported sick, and a replacement staff member could not be recruited.
At 7.45pm on 2 April 2020 Mr Z and Staff Nurse 1 began the night shift in Unit 1.
The NIRP spoke to Staff Nurse 1 who outlined the night-time routine which began with medication dispensing, assisting people who required help to get into bed as well as nighttime tea and snacks.
Sometime between 0100 and 0200, Staff Nurse 1 and Mr Z helped a resident back to bed. Staff Nurse 1 recalled that this part of the evening was "extremely busy".
In the early hours of the morning, Staff Nurse 1 went to the nurse's station to write up care plans and complete outstanding paperwork where she stayed for most of the night.
She stated that she did not hear or see anything untoward throughout the night and recollected that at around 0400 Mr Z came to the nurses' station, where he had a glass of water from the cooler and asked her when she planned to do her rounds.
She informed him that she would begin around 0530.
At 0530, Staff Nurse 1 began her rounds and provided personal care to some of the residents.
At around 0600 that morning, Staff Nurse 1 observed Emily through the window in her door, lying still, apparently sleeping and wrote in Emily's notes, "(Emily) settled well overnight. Nil complaints overnight".
Staff Nurse 1 explained to the NIRP review team that Emily was very independent and didn’t require much supervision or assistance at night.
The night staff ended their shift at 0800 and the day staff took over.
At 0815, Healthcare Assistant A went to Emily's room and recorded that Emily became tearful and said she wanted to tell her about what happened during the night.
Healthcare Assistant A recorded that "Emily alleged that Mr Z had come into the room and 'was on top of me and raped me'. She repeated this again and then said, 'I have to tell people'. I reassured Emily and then I called Staff Nurse 2."
Staff Nurse 2 attended to Emily immediately, who repeated the same information to her. Staff Nurse 2 then reported the allegation to the Clinical Nurse Manager (CNMII A) who also visited Emily in her room.
At 0830, Emily also told the clinical Nurse Manager A (CNMII A) that Mr Z had come into her room a couple of times on the same night prior to the incident.
She did not ring the bell at any stage. She said she was sore 'down below' and CNMII A asked Staff Nurse 2 and Healthcare Assistant A to do a unit urinalysis and a physical examination of her groin area.
The CNMII A reassured Emily that Mr Z would not be allowed to come near her again.
The Director of Nursing - who is the person in charge - was informed at around 1030 and planned a Multidisciplinary Team meeting for the afternoon.
At this stage Emily was upset and had told three people, so the Director of Nursing did not speak to her at this time.
The NIRP review team also spoke to Emily’s family.
At 1315 a family member rang Emily's phone as they would normally to check in to see how her day was going, however, there was no answer.
The family member said Emily did not call her back which was unusual.
At 1420 the family member rang Emily's phone again. This time Emily answered the phone sounding very upset and crying saying "I can't.. can't".
Her family member explained that the Nursing Home’s Director of Nursing came on the phone and informed her of what Emily had said.
The Director of Nursing (DON) had a different recollection of the sequence of events.
The Director of Nursing told the NIRP review team that following a conversation she had with Emily, Emily requested to make the disclosure to her family herself and requested the DON to assist her in making the phone call.
The Director of Nursing recalled Emily contacting her family member by using her own mobile phone.
However, due to distress Emily was unable to speak to her family member and make the disclosure, and instead handed the phone to the DON.
Following this conversation her family member was facilitated to visit her mother in the nursing home (in full PPE due to Covid-19 restrictions) that afternoon and the Director of Nursing kept her informed of developments during the evening.
The NIRP found a difference in the timeline and sequence of events relating to initial communication with Emily's family provided by the nursing home management and Emily's family's recollection, which it was "unable to reconcile".
Emily's family are adamant that they were informed of the allegation when a family member rang Emily's personal mobile phone.
There were no contemporaneous notes at the time and the NIRP has pointed out the need for contemporaneous notes to be completed especially in a crisis.
Between 1545 and 1630 the Director of Nursing stated that she reported the allegation to the local garda station and to the head of older persons services at the Community Healthcare Organisation who agreed to contact human resources regarding the management of Mr Z.
The Director of Nursing also contacted a Sexual Assault Treatment Unit who advised on the process of scheduling an appointment for forensic medical examination via An Garda Síochána.
They also provided advice to the Director of Nursing on how to preserve evidence.
An Garda Síochána subsequently made an appointment for Emily to attend the Sexual Assault Treatment Unit that evening.
Emily's daughter asked to accompany her mother. However, the Director of Nursing explained that due to Covid-19 restrictions she would be unable to do so and suggested that the Director of Nursing would accompany her instead.
At 1630, the head of human resources in the Community Healthcare Organisation rang the Director of Nursing regarding Mr Z who was due on duty at 1945 to advise that attempts should be made to contact him by phone to advise him that an allegation had been made against him and that he was not to report for duty until the Director of Nursing made contact with him.
In the absence of telephone contact, it was suggested that he be met at the entrance to the unit by a manager and asked not to come on duty.
At 1945 Mr Z attended the nursing home for duty and was met by CNMII A, who followed the HR advice; informing Mr Z that an allegation had been made against him and that he was to return home and await contact from the Director of Nursing.
At 1830 four gardaí went to the nursing home. Two gardaí spoke with Emily, and two examined the CCTV recordings. The Garda forensic team then attended the unit and removed clothing and personal items from Emily's room.
The Director of Nursing recorded in her chronology of events: "Gardaí advised me not to disclose this incident to any other staff members. When informed about the organisational investigation process, I was advised not to speak to any staff member until gardaí spoke to the relevant staff members."
Staff Nurse 1 who had been on duty the previous night came on duty as planned, however, the allegation was not discussed with her in accordance with advice received from gardaí.
Staff Nurse 1 went off duty the following morning and remained unaware of the allegation until she was telephoned by the gardaí later in the week.
She stated to the NIRP that she was deeply shocked and distressed that this could have happened to a resident while she was on duty.
At 2200 on the date in question Emily returned to the unit with the Director of Nursing.
Shortly after her return to the unit, Emily was ill and vomited. She was then assisted by Staff Nurse 1 to wash and prepare for bed.
Follow up care
The report states that the events of 3 April 2020 severely impacted on Emily, who developed symptoms of acute stress reaction in the immediate aftermath and according to her treating consultant psychiatrist, subsequently developed post-traumatic stress disorder (PTSD).
PTSD is a severe reaction to an event which overwhelms the human ability to cope, accompanied by intense fear, helplessness, loss of control and has a lasting impact on the individual.
Emily's reaction was an expected response to what was a deeply distressing, traumatic event.
Emily's mood deteriorated after the sexual assault. She had periods of distress, anxiety and irritability as well as a fear of strangers which were understandable responses to a horrific event.
Initially, Emily's consultant psychiatrist advised active monitoring and watchful waiting with frequent observation to maintain safety as recommended in the National Institute for Health and Care excellence (NICE) guidelines for PTSD (2018).
However, as time elapsed Emily began to articulate suicidal thoughts and became withdrawn to her room for a time.
Emily's consultant psychiatrist informed the review team that over time the trauma from the incident did settle for Emily however, this was also in the context of Emily becoming more unwell and impaired which may also have accounted for her reduction in PTSD symptoms.
Emily's family explained to the review team that their mother had become very frightened at night requiring someone to thoroughly check her room, under the bed, the bathroom and behind the curtains to assure her that no one was there.
In addition to this, for a period of time Emily did not want the window in her room or the curtains open as she had started to believe that someone was watching her.
Emily was offered the option of option of moving to a different room or even the possibility of moving to a different nursing home.
Emily made the decision to stay in the nursing home and also in her own room, choosing to have her bed moved to a different part of the room.
Personal care
Support with personal care, particularly showering, became especially difficult for Emily, more so when staff who Emily was unfamiliar with supported her.
Emily's family explained to the review team that Emily was supported with great compassion by a Healthcare Assistant (given the pseudonym HCA B in the report).
HCA B was a great support and comfort after the assault.
However, at the beginning of 2021 Emily's family learned that HCA B was moved to a different part of the nursing home.
Emily's family explained that the loss of HCA B was devastating to Emily as she had provided her with an important sense of security in the aftermath of the incident in April 2020.
The nursing home management informed the NIRP review team that the rotation of staff every six months was practice within the facility, in order to ensure that all staff were familiar with the support needs of all residents.
The management of the nursing home also informed the review team that although HCA B was rotated to another unit, it was agreed that when she was on duty, she could provide personal care and support to Emily.
Emily's family reported to the NIRP review team on 26 January 2020, their mother was upset and distressed and said "l am broken, now, they have broken me".
Her distress was apparently due to being showered by a carer with whom she was not familiar.
Following this, the family had a phone call with the nursing home management and agreed four staff in addition to HCA B to provide care and support to their mother.
At a meeting on 10 February 2021 between the NIRP review team and Emily's family, Emily's family reported how unhappy they were about the care that Emily was receiving particularly in relation to personal care and showering.
The NIRP immediately escalated the family's concerns to the head of older persons within the CHO.
Following the death of Emily in 2021, the family met the NIRP review team and the head of older persons services from the CHO.
The report states that the meeting was "emotional" and the family was "clearly angry and upset at a number of issues including the fact that HCA B was moved to another unit at a time when their mother really needed her".
The NIRP review team concluded that given the circumstances and the trauma Emily had suffered, more effort could and should have been made to make Emily's experience of showering and personal care more acceptable to her and her family.
Nonetheless, it acknowledged that the challenges presented by Covid-19 were a contributing factor to Emily’s support needs not being met the way she required.
The Rape Crisis Centre can be contacted on its freephone national helpline at 1800 77 8888, at any time of day or night.
