The system established in Northern Ireland to safeguard the most vulnerable adults failed an elderly dementia patient.
After going three months without a shower, Stanley O'Neill was discovered with a cord wrapped around his neck.
These and other failings weren't reported for adult safeguarding investigations despite medical recommendations.
In a review, the nursing home was criticized for not being honest and open with the 79-year-old's family.
At the hospital, Mr. O'Neill passed away on December 20, 2021.
A Belfast Trust investigation found a number of shortcomings in his care that, according to his family, have left them "devastated.".
Bradley Manor Care Home expressed its condolences and regret to Mr. O'Neill's family in a statement.
A spokesperson stated, "Our residents' safety is, and always has been, of the utmost importance to us, but on this occasion, we failed to meet some high standards that are rightfully expected of us.
"Although we make no excuses, the Covid-19 pandemic was a historically significant time for the adult social care sector. We faced particular stresses and an extraordinarily difficult environment. ".
When employees, family members, or patients express concerns about the welfare of vulnerable adults within the healthcare system, the adult safeguarding system is designed to provide protection. .
The Northern Ireland public healthcare watchdog, however, claimed in an interview with BBC News NI that vulnerable adults in Northern Ireland were being neglected. .
Grandpa O'Neill and Sophie O'Neill had a very close relationship; she referred to him as "the rock" of her family. .
But when Stanley O'Neill was diagnosed with dementia, everything changed. .
A number of nursing home and hospital stays followed as things at home became unmanageable. .
Mr. O'Neill moved into Bradley Manor in north Belfast in January 2021, during the pandemic. After a stay in the hospital, the Belfast Trust assigned him to that location.
His granddaughter Sophie claimed that a number of worrying incidents were reported to her family.
"At first, there were two nighttime falls that went unnoticed, and we were concerned, but then I saw that his call bell had been taken out of his room," she said. .
"I asked staff, and they said he was seen wrapping the cord around his neck, and they had removed it. It was only passed onto us a few weeks later. " .
I was completely shocked and puzzled as to why it had taken so long to inform his family, Sophie continued. .
"So for me, there were safety concerns, but nothing was done. " .
In December 2021, when Sophie's grandfather was taken to the hospital, she claims she first heard the phrase "safeguarding referral.". .
Mr. O'Neill was taken to the Mater Hospital in Belfast after Sophie discovered him unconscious in his Bradley Manor room. .
When I arrived, a member of the hospital staff told me they were worried about Grandad.
"They claimed that his oral hygiene was the worst they had ever witnessed, and at that point, the hospital began discussing a referral for adult safeguarding. " .
14 days after being admitted to the hospital on December 6, Stanley O'Neill passed away.
Investigators were not aware that he had passed away when his family was not informed of the adult safeguarding referral until two days after his death. .
The coroner has been given the case, and he or she will eventually determine the formal cause of death.
"This was too late for my granddad," said Sophie. "The whole point of a safeguarding referral is to protect someone. ".
The Belfast Trust ultimately looked into the case of Stanley O'Neill as a Serious Adverse Incident. .
A serious adverse event is any situation that caused or might have caused serious unintended or unexpected harm to patients. Within 12 weeks of the reporting date of the incident, investigation reports must be submitted.
A draft of the report was given to his family in April 2023. What was discovered was:.
- There were some areas of Mr. O'Neill's care in Bradley Manor during the final three months of his life that did not meet the expected standard.
- There was a failure to interact with the family in order to more effectively and openly communicate with them.
- The final three months of Mr. O'Neill's life were spent without a shower.
- a nursing home's failure to offer adequate oral care.
- The nursing home noted instances of Mr. O'Neill's aggression while providing personal care.
- It did not suggest any changes to prevent or lessen future falls after a number of falls in the nursing home.
- It was not handled as an adult safeguarding incident when Mr. O'Neill was discovered with a call bell cord around his neck, and the family was not promptly notified.
- The cause of an incident or how it should be reported was not always clear to the staff.
- Adult safeguarding received a referral regarding yet another incident in which Mr. O'Neill was seen hitting a fellow resident. Although his family was not informed, it was thought to be a sign of his worsening condition.
All parties involved in Mr. O'Neill's care, the report found, had failed.
Learning letters on how to handle adult safeguarding issues have been distributed to health and social care staff in response to the report into Mr. O'Neill's case.
From 4,778 in 2019 to 6,897 in 2021, Northern Ireland has seen an increase in the number of referrals for adult safeguarding. .
The increase may be related to "greater public awareness of adult abuse," according to the Department of Health. .
The shortcomings in Mr. O'Neill's case come at a time when the Northern Ireland Public Services Ombudsman (NIPSO) has expressed concerns about the adult safeguarding system in Northern Ireland.
"I think it is clear from a number of cases that have come into my office that our adult safeguarding system is not fit for purpose," ombudsman Margaret Kelly said.
"A lot of the time, it has been up to families to alert medical staff to potential care deficiencies, and that is wrong. " .
In seven of the eight nursing and care home cases the ombudsman's office handled in recent years, there was a problem with adult safeguarding.
Cases handled by the Ombudsman included:.
- Someone who choked, then vomited, after being improperly positioned in a bed.
- a patient who was underfed and had some degree of malnutrition.
- adult not receiving pain medication due to learning disability.
- When a resident was not properly cared for, she broke her leg and choked on her dentures for 24 hours before the nursing home realized what had happened.
Although these cases demonstrate serious shortcomings, Ms. Kelly believes they are just the tip of the iceberg.
"Northern Ireland is in danger of falling behind when it comes to safeguarding our most vulnerable," she continued. " .
Despite promises from a number of health ministers to do so, Northern Ireland remains the only region of the UK and Ireland without specific adult safeguarding legislation.
A new adult safeguarding bill will be introduced once the Northern Ireland Executive and Assembly reconvenes, according to the Department of Health, which acknowledged that the current law has "shortfalls.".
The well-being of its residents, according to Bradley Manor, is its primary concern, and it has already made a number of changes to address the shortcomings noted in the report.
The Belfast Trust reported that it had increased monitoring at the nursing home and worked to put quality and safety improvements in place. .
Sophie said, thinking back on her grandfather's situation, "If any other families go through this, I just advise them to not be afraid to speak up for your loved one. " .
In Care Failed.
a flawed system of protection. A family looking for solutions. Here is Stanley's tale.
On BBC iPlayer right now (UK only).
