THE SOCIAL SERVICES INQUIRY REPORT

“1.1. On the 19th of April 1999 at 10am, Mrs Chubb and Mrs Hook, care staff from Isard House, attended the Civic Centre offices and handed over written statements by seven members of staff concerning issues of abuse and neglect of residents at Isard House. The complaints were specifically regarding the conduct of the staff on unit 3 towards residents between June 98 and March 99”

“ The statements were received by Monica Handscomb of R.I.D ( Social Services) and Richard Turner Principle registration Inspection Manager. Relevant matters were referred to the Police, a Social Services inquiry team was set up to investigate allegations about the care and medication of residents on unit 3”

“ 1.2. Carole Newton, operations manager ( BUPA) attended a meeting with Social Services staff later that day whereupon she was informed of the nature of the allegations”

“ The allegations fall into four groups,
a) Physical and verbal abuse of residents which include a degree of assault.
b) The management of medication.
c) Neglect, lack of care and theft.
d) Failure of managers to investigate and respond to incidents of abuse and neglect

“ 4.1.7. The residents on unit 3 are both physically and mentally frail with moderate to high levels of dependency requiring an intensive degree of personal care. These residents suffer a high degree of dementia and are unable to voice their concerns or remember situations that have affected them. They no longer have the capacity to represent their own interests, they are in affect totally dependent on the care of those around them for their most basic daily needs”

“ 4.3.1. Of the 27 allegations of abuse ten were identified by the Police for consideration as a degree of physical abuse or assault was possibly involved, however the Police were unable to bring criminal charges as the allegations were out of time for the purposes of charging and issuing summonses”

“ 4.3.2. Four members of staff have been identified by witnesses as allegedly assaulting, threatening, or intimidating residents, these allegations include,
a) Pushing a resident up against a wall.
b) Putting a fist under a residents chin.
c) Kicking a resident on the ankle.
d) Pushing a resident in the back causing her to topple forward.
e) Pushing a residents head against a fall with a fist.
f) Shouting at residents who were incontinent.
g) Flicking food in the face of a resident.
h) Wiping a residents face with a flannel coated in Faeces.
i) Spitting in residents face.
j) Swearing at residents.”

“ 4.5.1. Allegations of medical neglect, other then medication, lack of care or emotionally abusing behaviour are cited as follows,
a) Knowingly depriving a resident of her newspaper.
b) Poor catheter management, a residents catheter was repeatedly over full which could have caused medical damage.
c) Insufficient regard for first aid procedures, i.e. when picking up residents of the floor after they had suffered serious injuries.
d) Failure by staff to call a G.P when real concerns of a medical nature had been identified by junior staff.
e) Residents left in bed for long periods of the morning to await later shift staff.
f) Sedated residents with their face in their food.
g) Residents not cleaned after eating.
h) Two residents were kept in a lounge isolated on a regular daily basis.
i) Inappropriate restraint of residents, by gripping wrists causing bruising.
j) Residents left in urine soaked clothing with resultant sores.
k) Lack of attention to dental problems i.e. where residents were left in pain or discomfort.
l) Residents biscuits and sweets taken.
m) One resident found slumped in a chair with an orange drink covered in ants.
n) Residents found dehydrated and not being assisted to drink.”

THE CONCLUSIONS OF THE SOCIAL SERVICES INQUIRY REPORT

“ Concerns about the poor conduct of staff on unit 3 have been corroborated by the independent medical audit, personnel records and the statements made by witnesses who were not directly employed on the unit,
vi) Residents were not always given apperients causing confusion and complications with the possible outcome of distress and discomfort, indicating a disregard of residents needs and neglecting residents medical conditions”

“v) There have been reported to the inquiry team witnessed incidents of medication left out in pots and not given, elderly mentally infirm residents in possession of medication.
There has been unclear dispensing of Largactil, Chlorpromazine, involving inconsistent doses for which there is no evidence of G.P authorisation”

“ 5.36. Maria Keenaghan is responsible for a substantial breech of section 9 of The Residential Care regulations 1984, further breeches have occurred under section 6, and sections 10.1.”

“ 5.17. Drugs were not given properly on unit 3 and found in communal areas, the medication regime on unit 3 did not ensure that regulation 10.1 (Q) of the regulations which require for the recording,safekeeping, handling and disposal of drugs, was complied with”

“ 5.20. A significant amount of residents clothing has gone missing, new clothing amounting to many hundreds of pounds, this has caused physical hardship to residents and families”

“ 5.18. Accessing medical intervention was a responsibility undertaken by the head of care, consideration for the welfare of residents has been adversely affected, reports by members of staff suggest the visiting medical officer was unable to be present promptly, either because he was too busy or his presence was considered unnecessary”
“ 6.0. Although the witnessed incidents of physical abuse are not recent there is a significant number of witnesses, amongst care staff in the home, relatives and others who have been interviewed and who corroborate the original allegations”

“ 6.2. A climate of complacency and laxness occurred in terms of the care of residents particularly on unit 3, inappropriate behaviour towards them did occur in the manner suggested by the witnesses and those subsequently interviewed”

“ 6.16. The outcome of this inquiry concludes that on unit 3 for a period between June 1998 and March 1999, a number of incidents occurred which were unacceptable in the terms of the conduct and of the staff and management of the welfare of the residents, as such section 9 of the Residential Care Homes Act 1984 has been breached in this respect”

“ 6.17. The managing agents of the home, BUPA, appear to have failed to ensure the effective line management on unit 3, where the most highly dependent residents with dementia are being cared for. Although it is accepted that the operational manager visited the home to the statutory requirements but was unaware of any shortfalls in the care provided on unit 3”

LETTER FROM THE DAUGHTER OF THE ABUSED RESIDENT A.B, DATED MARCH 26TH 1999, SENT TO,
CAROLE JONES ( HOME MANAGER)
CAROLE NEWTON ( BUPA)
DES KELLY (BUPA)
MONICA HANDSCOMB ( SOCIAL SERVICES)

“ Dear Carol Jones,
On receiving your letter this morning dated, 24/3/99, I feel that I must finally respond to this letter and the letter I received previously dated, 5/6/98, a copy enclosed, I would like to state first and foremost that my primary concern is my Mothers welfare and quality of life”

“ In your letter you refer to my loud and aggressive manner claiming that my behaviour was inappropriate for the environment and caused obvious distress to residents, visitors and staff in the immediate vicinity, and that if I had any further concerns I should bring them to your attention in the privacy of your office. I beg to disagree with your judgement of me, I would like to state that in my opinion and my brothers who was there at the time, I was understandably highly distressed and exceptionally frustrated that despite my repeated requests over a considerable amount of time, my Mothers hearing has been neglected”

“ My Mother is unable to communicate in any way with her own Daughter and family, she is oblivious to the world around her, she lives in a silent world completely unnecessarily, I would also like to state that a visitor who was there at the time, did not seem distressed by my manner, but was in fact in agreement with me, she commented
“ That it wasn’t worthwhile complaining, because she had complained previously about her Mothers care and had been told, if she didn’t like it, she could take her Mother somewhere else”. I found this very difficult to believe until I received your letter in which you said, ( If you are not satisfied with this care, you are quite welcome to remove your Mother from Isard House and place her in a care establishment of your own) you also said in your letter, I would therefore request that if you have any further concerns that you bring them to my attention in the privacy of my office”

“ I should like to point out that after our confrontation when things had settled down, I took my Mother out into the garden with my Brother, it was you who pursued me and tried to continue the confrontation which was very upsetting for me and especially my Mother, my Brother asked you to go away and leave us alone, no fewer then four times before you eventually stormed off”

“ As for your comments about me such as loud and aggressive, emotionally disturbing behaviour, displays of aggression towards staff, I can only suggest that you have manipulated the situation for your own benefit to cover yourself. I realise now I should have reacted immediately and contacted the necessary complaints department, but as I say my Mothers welfare is paramount and did not wish to cause a scene, however due to this more serious incident and your response to it in your second letter, I feel I must follow the correct procedures and guidelines for complaints as you outline in your first letter, as the situation appears to not improve but become more serious”

“ On other occasions when visiting my Mother and trying to communicate with her I soon became aware she was unable to hear me and the hearing aid was not working again. For the last few months I have brought spare batteries with me to replace the flat ones, I do this so I do not have to encounter your hostility and aggression”

“ I feel it is no exaggeration to say that on no more then six occasions has my Mother been unable to hear me, when her ears were first tested, the specialist told me that it was vital that she should hear at all times as it slows down the deterioration of her brain and memory, I can not express how upset I feel as I walk towards her and can tell by her vacant expression that she is in a silent and distant world and I wonder how long she has been like that since my last visit”

“ Within a few minutes of me inserting a battery in her hearing aid her expression changes, she becomes alert and happy to see me, its absolutely unnecessary, I hold you fully responsible for my Mothers state of loneliness, isolation, deterioration as you accepted full responsibility yourself, you stated in your first letter ( I personally do spot checks on all residents to ensure they are wearing appropriate Aids correctly) although in your letter you seem to manipulate the situation and fill then with guilt trip tactics, you fail to mention the actual reasons behind, there was another incident which you are fully aware of as I phoned you personally to discuss it”

“ I arrived at the home to take my Mother out and to be blunt she smelt vile, the staff changed her and we went for lunch, at the restaurant I took her to the toilet and she was overcome with pain on urinating, the foul smelling urine and the fact that she could only pass about a teaspoon of very dark brown liquid was obvious to me that she had a very severe urine infection, I took her back to the home and told staff and their response was that they knew, I spoke to you then and there and you told me that you were aware of it and although she had not seen a doctor or received any medical attention, doctors usually feel it better to let these things clear up on their own, I would like to ask you how you would feel if you were enduring the same terrible pain and other symptoms what you might do? I don’t think you would simply sit it out. You show no consideration for the pain my Mother was going through, I was very calm almost submissive in hoping that this would be more beneficial and advantageous attitude to adopt in relation to my Mothers welfare, I then phoned you directly to ask that my Mother see a doctor as soon as possible, she was then administered antibiotics, I would like these distressing and serious matters to be dealt with promptly, I will be sending copies of this letter to the department you kindly suggested, M.L”

EXTRACTS FROM INDEPENDENT WITNESSES, WHICH WERE ALSO SUBMITTED TO THE ASHFORD EMPLOYMENT TRIBUNAL.

1. Hairdresser K.
“ K. is a hairdresser at Isard House and really enjoys the residents, whilst hairdressing she went to fetch a resident to have her hair done and saw Sarah Conway serving lunch, she was at R.S,s table and she saw R.S suddenly flinch and saw Sarah Conway flicking peas or gravy at her, R.S said don’t flick that at me and Sarah Conway said I didn’t it was you. I feel Sarah Conway had a funny way of caring for residents and she definitely has a big attitude problem”

2. “ The doctor who sent her to hospital for a check-up, the hospital found nothing but she had an erratic heart beat, I phoned Carol Jones ( Home Manager) to tell her Mother was being admitted, then they changed there minds, stating because the erratic heart beat was due to the medication she was taking, Accident and Emergency unit gave me a letter to give Carole Jones”

3. “Mrs L often found her Mother wet, she would visit in the afternoon, her Mother was always sitting at the table”

4. “ With regard to numerous items of clothing that have gone missing from Mrs F, BUPA have agreed to compensate Mrs L for the financial loss but she did state that a women from BUPA was walking about asking staff whether her Mother really did have the things that Mrs L had claimed she had, she overheard this and found this to be quite insulting”

5. “ Mrs A, found Jackie Walters a little aggressive in her manner towards R, A.R kept wandering so Jackie pushed her in a chair and pushed the chair up to the table so she couldn’t get out, she felt Carole Jones had too much to do”

6. “ I asked Carole Jones attitude responsiveness towards her, Mrs L stated that she heard me but doesn’t listen”

7. “ The previous day I went past the T.V room couldn’t find anybody, couldn’t find her clothes i.e. my Mothers, no bra, knickers, shoes etc, Carol Jones was doing her paperwork and she said, just a moment, I said I want you to look at this now, where are the staff, no staff on the unit, where are my Mothers clothes”

8. “ Mrs Fs G.P came out for the second time to look at my Mothers legs on a Thursday morning, 2 lots of cream were provided and tablets for water retention, this occurred on the 25th of May, on the morning of Tuesday by the afternoon the prescription had arrived, only last week I found the tube opened up the box and found it had not been opened, they had been using the wash solution but not the cream, I witnessed this on the 3rd of June”

9. “When Mrs B was seen by audiology they made her another hearing aid, at a later stage she was seen by the audiology department at K, and they removed a large piece of hard wax the size of an olive”

10. “ bruising was found on her face by her daughter approximately a year ago, a careworker has since left and said Mrs B, had fallen out of bed”

11. Heavy patterned cardigan was missing, dark edging, navy/black with red/green pattern, two other cardigans missing, one cream, one yellow, Mrs L said her Mother did own a green and blue cardigan but was unsure if she still had it, she will check, she also had a full length raincoat, cream coloured went missing, it was a Weatherall Berkertex, plain lining six 16”

12. “ Personal went down in the last few months of her stay at Isard”

13. “ Mrs B, had a urine infection, Mrs L was told by Carol Jones that they preferred this to clear up in its own time, Mrs L thought about this and how much pain her Mother was in and Telephoned Carole Jones to say she wanted her Mother to see the G.P, Mrs B was then prescribed antibiotics, daughter finally decided to remove her Mother from Isard after she had received the letter dated 24/3/99, from Carole Jones, Mrs L told the manager that she was taking her Mother home for the weekend and placed her at K, see how this works out, later told Carol Jones her Mother would not be returning back”

14. “ Mrs L went on to say that the key workers Renee Warwick and also Eileen Chubb were absolutely brilliant, I also asked whether she found Maggy roffy to be good as well and she said maggy was fine, Mrs L said they all had a brilliant attitude towards all the elderly people”

15. “ Eileen Chubb had got her on her tablets properly now, she apparently didn’t need the quantity she had been given, but as I have pulled so many alarm bells I feel I cant ask Carole Jones to look at the medication charts, I know I am being a nuisance “

THE FOLLOWING SECTION DETAILS THE INDEPENDENT DOCUMENTARY EVIDENCE ON DRUG ABUSE AND IS CONTAINED IN THE FORMAL WRITTEN SUBMISSIONS MADE BY COUNSEL FOR THE BUPA SEVEN, TO THE EMPLOYMENT TRIBUNAL.

ALL MEDICATION RECORDS REFERED TO IN THIS SECTION ARE AVAILABLE FOR INSPECTION IN THE M.A.R SECTION.

Counsel, Ian Scott of Old Sq. Chambers

“ At paragraph 31 of her statement to the Tribunal, Eileen Chubb referred to the treatment of E.P with excessive amounts of Chlorpromazine, she referred to this matter in her interview with Social Services on the 22nd of April 1999 ( Page 24, B4) An examination of the relevant M.A.R sheets demonstrates that such overdosing was being carried out, in particular, (pp32 and 33, B3) reflect the overdosing which was going on.
The Tribunal is asked to note at (p33) that the label dated 21st of April 1999 prescribing 4 to 6, 5ml spoonfuls of Chlorpromazine to be taken three times daily was struck over the label at ( p32) prescribing 4mls spoonfuls three times a day. The Tribunal is also asked to note that this was likely to have been done on the day that Social Services unit entered the home to begin its investigation, 21st of April, it is submitted that a reasonable interpretation of the act of sticking the label dated 21st of April 99 over the previous label is to hide the repeated unauthorised overdosing of Chlorpromazine, at a level of 30mls, 3 times a day by Maria Keenaghan which had taken place from the 3rd of April to the 23rd of April 99. When confronted by this evidence, Maria Keenaghan sought to argue it away by suggesting that she was merely carrying out what had previously been properly given by the previous month. When the previous months sheets were examined ( p31, B3) the label for the dosage was missing altogether. Furthermore when asked Maria Keenaghan was not sure what the doses on the missing label was likely to have been and made a number of suggestions including lower doses then those recorded as being given”

“ It is in the area of the administration of medication that objective evidence on which the reasonable beliefs as to malpractice is clearest, in particular, in the statement of Eileen Chubb ( paragraphs 14, 31, 49) specific allegations are made. In respect of paragraph 49, Maria Keenaghan in cross examination accepted that the seals on the drugs for M.C and M.B were not broken but the M.A.R sheet had been signed off by her as if the drugs had been administered. It was also accepted by Maria Keenaghan during her interviews with Social Services ( B4 p 110) which she accepted was a accurate note of her interview. The complaints made about this to Social Services investigation unit are at ( p25B4) and her hand written statement at (p35B4). The Tribunal is also referred to the note of the investigation interview held with Maria Keenaghan, by Des Kelly on August 10th 1999, ( p173B4) in which she indicates that she was judging what Chlorpromazine to give. She says she would always inform the G.P, but there is no evidence of the G.P signing the M.A.R sheets to authorise the variation from the dosage set out on the label, despite the evidence that the G.P regularly visited the home”

“ The Tribunal is further referred to the evidence of Amanda Chumley given during the investigation by Social Services, which corroborates paragraph 31 of Eileen Chubb’s statement about an earlier event of overdosing of Chlorpromazine by Maria Keenaghan,
(p4aB4) Amanda Chumley signed the account of her interview, The M.A.R sheet is at 31a”

“ Further, BUPA owed a duty of care in common law to the residents that they would be not be cared for negligently, the applicants ( BUPA Seven) allegations amounted to at the very least negligent levels of care being provided, and without prejudice administration of drugs in excess of the prescribed levels was carried out knowingly by Maria Keenaghan”

“ Further Eileen Chubb’s concerns about the state of the M.A.R sheets on unit 3 and the administration of medication have been borne out by the report of the independent pharmacist (p43 to 48 B3) which was undertaken as part of the investigation by Social Service, The Tribunal is particularly directed to the findings in the report in respect of E.P at item 5 ( P45) and D.H at item (14p46)”

“ In the case of D.H it is another case in which the disclosures made by the applicants ( BUPA Seven) are borne out by an objective examination of the M.A.R sheets and the pharmacists report. Mrs Cox for the respondent( BUPA) stated that during the hearing that whether or not D.H was constipated was in issue, the relevant concerns are set out in the witness statement of Eileen Chubb at paragraph 34 and 35 and the statement of Lee Elkins at paragraph 17 to 19. It was apparent from the relevant M.A.R sheets ( p38B3) that Lactulose which is not prescribed as P.R.N ( i.e. as required) has routinely not been given. Maria Keenaghan stated in evidence that it was her handwriting at the bottom of the sheets which stated ( loose bowels due to antibiotics) it is not known when Maria Keenaghan wrote those words on the sheet, despite the routine non-administration of Lactulose shown on the sheet the G.P does not appear to have authorised a change in the label to indicate it should be given as required ( i.e. discretionary as shown by the letters P.R.N) in any event the suggestion that Lactulose was not being given as D.H had ( Loose bowels) is contrary to the entry on the next sheet(p39) for Codanthrusate dated 25th of March 1999, which is shown as being administrated on the days prior to D.H going into hospital. Codanthrusate is a strong laxative, it is recorded in the independent pharmacists report as being given on three nights before D.H goes into hospital( p46B3) the evidence thus supports the complaints made by Eileen Chubb and Lee Elkins that D.H was seriously constipated at the time they saw her and Lactulose had been withheld”

“ In respect of the complaints about administration of medicine the Tribunal is also invited to take into account the whole entry by the independent pharmacists in respect of D.H ( p46B3) which includes a reference to the M.A.R sheet for February possibly being for another month as it was not dated. Further the Tribunal is invited to draw the conclusion on the basis of the report that there was serious failings in the system of administration of medication at the home and that the applicants ( BUPA Seven) who made the complaints about it had good reason to do so”

“ D.H that there was serious problems relating to the administration of medication. These include overdosing E.P by Maria Keenaghan with Chlorpromazine, a proper examination of the M.A.R sheets at the time would have revealed the failings”

“As further evidence of such an attitude when Eileen Chubb had made a complaint to her about Maria Keenahans poor medication practices she made only a cursory snap shot examination of the position and found nothing serious to be concerned about. It is clear from the independent pharmacists report ( pp43-48B3) and the evidence before the Tribunal of the contents of M.A.R sheets in respect of E.P and D.H”

THE CASE FOR REASONABLE BELIEF
“ The requirement of a reasonable belief on the part of the applicants is a common requirement to section 44(1) ( c and (e together with 43B (1 43g (1 (B and 43H (1 (b E.R.A to establish reasonable belief the applicants are not required to establish on the balance of probability that the subject matter of their disclosures were true. It is simply required that the applicants help their beliefs as fact and that they were reasonable to do so, even if ( which is denied) there were mistaken the applicants could proberly be found to have held reasonable belief further in cases such as this where a number of applicants disclosures are based on an account of their own observations and experiences without corroborating witnesses and thus amounts to one word against another, whether a reasonable belief was held will involve the Tribunal in an assessment of credibility. It is submitted that of direct relevance to such an assessment of reasonable belief in such allegations ( Where there is corroborating witness of evidence e.g. witnessing a push in the back of a resident or other abusive behaviour where the effect is transitory) are any other complaints made by an applicant where the Tribunal finds that there was evidence which shows that the subject matter of the complaints is demonstrated on the balance of probabilities and/or beyond reasonable doubt. It is submitted that such findings significantly add to the credibility of the applicants concerned and add weight to their reasonable belief in other complaints which depends only their there own observation or experiences about which there is no corroborating evidence. For example the Tribunals attention is drawn to the objective evidence of Eileen Chubb’s complaints about failures in Maria Keenahans administration of medication which in turn adds to the credibility of Eileen Chubb’s other complaints where such corroborating evidence is not available”

“ In addition to Carole Jones inadequate investigation of poor medication procedures made in response to Eileen Chubb’s complaints the respondents(BUPA) subsequent investigation carried out by Susan Greenwood Quality Assurance manager, appears to have been equally inadequate. Des Kelly’s evidence was that it result in few recommendations and there were no major concerns ( paragraph 42 of Des Kelly’s witness statement) it is not until an independent survey was carried out that the serious extent of the failings to apply proper medication procedures became clear. Such an inadequate response by BUPA to such serious complaints can only be taken as deliberate failure on their part to act on the complaints. Had the issue been taken seriously with the resources they had BUPA could have equally well have obtained expert advice about the administration of medication in the same way that Social service did once matters had been formally raised with them by the applicants.”

THE BELOW REPORTS WERE CARRIED OUT BY BUPA, PLEASE NOTE THAT THEY ARE IDENTICAL DISPITE ONE BEING BEFORE THE ALLIGATIONS AND THE OTHER CARRIED OUT WITH FULL KNOWLEDGE OF THE ALLIGATIONS
.............BUPA INTERNAL DRUG AUDIT
............BEFORE

2) Medication

2.1. The home uses the nomad system for medication administration.

2.2. All medications were securely and appropriately stored in accordance with local authority guidelines.

2.3. Photographs of residents are obtained for identification purposes.

2.4. General standards of administration recording was good.

2.5. It is recommended that reasons for non administration be recorded, the current practice documents (0) for omission but does not specify the reasons.

2.6. The recording of medication received from and returned to pharmacy was not evident on occasions. This must be consistently recorded to enable effective audit trailing of medication.

CAROL NEWTON OPERATIONS MANAGER BUPA. 23rd of March 99

............BUPA INTERNAL DRUG AUDIT
..........AFTER

2) Medication.

2.1. The home uses the nomad system for medication administration.

2.2. All medications were securely and appropriately stored in accordance with the local authority guidelines.

2.3. photographs of residents are obtained for identification purposes.

2.4. The general standard of administration recording was good.

2.5. It is recommended that the reasons for non administration be recorded.
The current practice documents (0) for omission but does not specify the reason.

2.6. The recording of medication received from and returned to pharmacy was not evident on occasions. This must be consistently recorded to enable effective audit and trailing of medications.

SUSAN GREENWOOD QUALITY ASSURENCE MANAGER. May 1999

The above report by Susan Greenwood is that which BUPA repeatedly refer to in their witness statements and on which they based their decision to re-deploy Maria Keenaghan, please see Des Kelly cross examination in harassment section