By Ailbhe Conneely - RTE News - 21.06.2023 [IRELAND] - [Mr.Z]
A governance review into a Health Service Executive-run nursing home, where a resident was sexually assaulted three years ago, has found that other residents had alleged incidents of sexual assault by the same healthcare worker. The report by the National Independent Review Panel (NIRP), seen by RTÉ News, states that none of the incidents were followed up in accordance with HSE safeguarding policy. In June 2020, a healthcare assistant ('Mr Z') who worked at the home was jailed for 11 years for the rape of a female resident who has been given the pseudonym 'Emily' for the purposes of the NIRP report. The NIRP, which reviews the most serious incidents in services run by the HSE, was commissioned by the HSE to complete an independent review of governance arrangements at the home. It sought to identify any learning opportunities or improvements that could lead to better safety for all residents in the nursing home and in other residential facilities across the country. It concluded that the undisputed rape of 'Emily' in April 2020 (when Covid-19 restrictions were in place), as well as her subsequent disclosure that this had happened before and the fact that there were previous, unreported, notifiable incidents, suggest it was not a one-off incident. According to the unpublished report, Mr Z's criminal behaviour only came to light as a result of the cognitive clarity, emotional strength and bravery of Emily, who passed away in 2021.
It said: "Emily’s actions and sacrifice undoubtedly helped convict her rapist and saved other vulnerable women from his predatory behaviour. "His behaviour as a sexual offender was thwarted by Emily and staff members who heard and loved her and who acted appropriately in securing his conviction. May she rest in peace."
When female residents made allegations against Mr Z in the past, the allegations were not believed, reported or followed up on, according to the NIRP. "It is recorded on the file of one resident, (now deceased) that she had informed a carer that she was 'raped' and that 'no one believes me'." A number of other residents also alleged to staff that they were "raped and assaulted" but these complaints, according to the NIRP, appear to have been ascribed to clinical causes such as delusions, hallucinations, delirium, confusion or urinary tract infections. Minister for Justice Helen McEntee said the incident is "hugely distressful" for all involved.
Speaking on RTÉ's Morning Ireland, she said that as is the case with with any allegation of sexual assault or rape, gardaí "will absolutely do their job and make sure that they follow up on all of the allegations" She said gardaí will also "ensure that the victims who have come forward and their families as well, that they are treated with utmost respect and supported through this time." The review found that many of the allegations of rape and sexual assault made by nine female residents were written in the file notes however, with one exception - it did not appear that any of them were followed up at the time with a safeguarding report or investigation.
"From interviews with staff, it was evident that there was a prevailing culture of disbelief that such sexual assaults could happen in their workplace. Most staff believed that these allegations had clinical/medical explanations related to the residents' conditions."
The NIRP report points out that sexual predators are often able to groom staff and the management into believing that they are not a threat to anyone.
The NIRP review team spoke to many members of the nursing home staff, none of whom believed (before his conviction) that Mr Z was capable of such a heinous crime.
His HR file showed that, in accordance with procedures, garda vetting was completed with nothing of concern noted.
None of the results from the checks would have indicated that Mr Z had a propensity for such abuse, according to the NIRP.
It is evident from the NIRP report that staff were greatly upset by the incident. Safeguarding team review
While the National Independent Review Panel was conducting its review, a separate but related piece of work got under way.
On 8 May 2020, the HSE Community Healthcare Organisation's risk manager drew the Chief Officer and Head of Older Persons' attention to Emily's psychiatry review in January 2020 (prior to the assault) where a concern regarding vaginal bleeding was documented.
The risk manager indicated to the NIRP review team that a wider review was required for a number of reasons including the severity of the assault, previous reports of vaginal bleeding from the victim, the timing of the assault at night (4am) and the fact that the assault took place during a period of restricted access to the unit because of the Covid-19 pandemic.
A Safeguarding and Protection Review Team (SPRT) got to work.
The team found reports in files that nine other residents in the nursing home had alleged reportable incidents of sexual assault by Mr Z, none of which were followed up in accordance with the HSE safeguarding policy.
The SPRT also found reports in files of two other residents who had reported physical abuse by Mr Z. All 11 incidents were reported to An Garda Síochána in line with the HSE's safeguarding policy and the residents' families were informed.
An Garda Síochána indicated that it was highly unlikely that any further prosecutions would follow "due to the fact that most of the alleged offences were committed against residents now deceased or residents who no longer had the capacity to make a formal complaint according to the report".
The NIRP liaised closely with the Safeguarding and Protection Review Team throughout the review to get a comprehensive picture of the safeguarding practices within the nursing home.
The NIRP accept that much of the information relating to previous concerns about Mr Z came to light largely with the benefit of hindsight and further investigation by the team of experienced social workers within the SPRT which reviewed 32 residents' files.
Overall, they found the files to have gaps in information and were difficult to navigate as they were not organised chronologically.
The SPRT also observed a practice in the nursing home whereby healthcare assistants were not permitted to make entries into the daily notes of residents.
Instead, they gave the updates to the nursing staff and relied on them to write into the residents' daily notes.
"This means second-hand information is being recorded in residents' notes which could lead to inaccurate information or misinterpretation of information. In the interests of safe care for residents it is imperative that their files are organised, easy to navigate and that important information about a resident is kept at the front of the file in the form of a profile or synopsis," according to the NIRP.
It said this was particularly important for new agency staff coming on duty to be able to pick up what’s going on in the home and respond appropriately.
According to the NIRP report, the SPRT would be providing a "comprehensive report" to the Serious Incident Management Team on its findings in due course.
It is understood that this report has been furnished to the HSE.
CEO of the Health Service Executive Bernard Gloster has apologised unreservedly.
He said concern remained with the family of Emily, and the families that have engaged with the HSE to date, and who it intends to engage with further on the wider safeguarding issues in the care facility. "We can only at this time unreservedly apologise, condemn what happened, and do all we can to ensure that safeguarding for all people in alternative care is at the highest level of priority for us."
Mr Gloster said he was not fully satisfied that all of the issues in the facility or those arising for the wider care context were fully understood. "In that respect I intend in the coming days to appoint a safeguarding expert from another jurisdiction to assist us."
Mr Gloster said it was important that "as the custodians of care services for older people that we say unequivocally that we failed Emily regardless of how much we were deceived by any one individual employee". He said he was anxious to ensure the wishes of Emily's family for privacy are respected.
He noted that given that it was such a serious incident, two reviews took place - one by NIRP and the second by the Safeguarding Review Team which sought to identify if there were other concerns which may or may not be connected to the case, and which require a safeguarding report to gardaí.
He said both of these reports have identified a number of issues. "The HSE will continue to engage further with the families of those who were in our care. We recognise that these issues will cause distress and concern for families of all people in care, and in particular those who may be most closely associated with this case, and therefore we are taking a very careful approach to meeting, informing and supporting these families." If you have been affected by any of the issues raised in this article, you can contact Dignity4Patients, whose helpline is open Monday to Thursday 10am to 4pm.
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