Case studies

In 2016 we received 11 complaints from parents on behalf of their children about the HSE’s HPV vaccination programme.  At the outset, we explained to parents that we have no clinical or scientific role to investigate any potential link between a child’s reported adverse reactions and the vaccine, nor the professional conduct of medical staff.

Following careful consideration of the collective nature of the complaints received, we decided to carry out an own volition examination of the general concerns about the HSE’s administrative actions that fell within our remit.

What we did

We examined the HSE’s administrative actions in relation to:

• Information provided to parents to inform decision making on the vaccination
• HSE guidelines for the reporting of adverse effects by the HSE Immunisation team to the Health Products Regulatory Authority
• Information on supports available to children and young people who reported adverse reactions

We sought information from the HSE and analysed the various issues involved.

Following the conclusion of our examination, we made the following encouragements to the HSE to improve the administration of the HPV school immunisation programme:

• to increase accessibility of the Patient Information Leaflet for parents and guardians further to those already provided by the HSE
• to provide greater clarity in their guidelines on the obligations of the HSE Immunisation Team to report adverse events to the Health Products Regulatory Authority.

We also encouraged the HSE to ensure that it clearly signposts the relevant pathways so that children and young people can directly access relevant health services and supports.

Outcome

The HSE’s information leaflet for 2017/2018 now includes a QR code and a link to access the manufacturer’s Patient Information Leaflet. Further, the HSE has amended the guidelines for the Immunisation Teams that provides greater clarity on their obligations to report adverse events to the Health Products Regulatory Authority.

With respect to supports for children and young people who report side effects, the HSE stated that it strives to provide the appropriate care for all patients no matter what their illness and that interagency liaison occurs when it is required in the care of each patient.

For more information see the OCO HPV Helpsheet.

Ciara was 1½ when her parents complained to us about the delay in a referral for a hip scan. Ciara’s parents told us that the method of referral from one hospital to another was done by fax. This resulted in one hospital sending the referral but the other hospital not receiving it. This delay resulted in the failure to diagnose, in a timely way, her condition which then required urgent treatment before she began to walk. Ciara’s parents raised concerns that the existing referral system may pose a risk to other patients, as it had to Ciara.

What we did

We carried out an examination of this complaint. We found that the administrative practice of faxing hip referrals from one hospital to another resulted in Ciara’s referral being lost. This negatively impacted on her. Our examination prompted a HSE review and they found that the process of sending and receiving referrals by fax between these two hospitals had resulted in a further 20 infants’ referrals being lost.

Outcome

Ciara received the necessary treatment and the hospitals made efforts to contact the families of the other 20 infants. The hospitals in question and the HSE accept that the practice of referral by way of fax is not appropriate or efficient. Both hospitals in this case undertook a review of the case and as a result they:

• Stopped the practice of faxing to refer between hospitals
• Jointly created a new system to ensure all referrals are captured
• Nominated members of staff to manage the system at both hospitals to ensure accountability
• Set up reviews and audits of the system to occur on a regular basis to ensure that it is effective

We informed the highest level of the HSE of the systemic failure that our examination highlighted. The HSE provided a report on the implementation of our recommendations and committed to improving scheduling and out-patient services on a national basis.

Tom’s mother contacted us in 2016. She told us that Tom had an intellectual disability that resulted in challenging behaviour. Because of this Tom could not live at home. The HSE had agreed that he needed a long term placement but had not provided funding for this. His mother was concerned because Tom was staying in a children’s hospital because the HSE had not provided a residential placement for him. He had been in the hospital for three months at that stage.

What we did

We immediately contacted the HSE. They responded by organising a teleconference so that we could speak to senior management about this complaint. They said that they knew that Tom needed a placement but they were having difficulty organising the funding for this. However, they subsequently advised that they would fund a place for Tom in a private facility.

Outcome

Tom was discharged from hospital and placed in a residential unit for children with a disability. His mother told us that he settled well there. She was of the view that our intervention prompted the HSE to find an appropriate placement for Tom. The HSE told us that Tom was one of a number of children in inappropriate placements. However, they couldn’t provide us with statistics. We closed this complaint but encouraged the HSE to collect data on the number of children with a disability who are placed inappropriately. We are concerned that this is a children’s rights issue and intend pursuing it further in 2017.

John was 14 years old and an in-patient at a private psychiatric hospital at the time his parents made a complaint to us. His parents explained that John was referred to the private hospital by CAMHS as the only treatment recommended and no public options were suggested.

When John was admitted to the hospital, the family was told that their health insurance company would not cover the treatment. While the hospital assessed that there was a clinical need for John to receive in-patient treatment, the family was not in a position to afford the treatment cost of more than €1,000 per day. The family told us that there was no public in-patient bed for John.

What we did

Based on the reported impact and on-going effect of this situation on John, we started an accelerated examination of the HSE’s involvement in this case. Our examination focused on obtaining information about the steps that the HSE was taking to meet John’s immediate needs and we encouraged resolution of this complaint at a local level.

By law, we can only investigate voluntary hospitals, which meant that it was not possible to examine the actions of the private hospital involved in this case. In relation to the health insurance company, we explained to the parents that they could bring a complaint to the Financial Services Ombudsman.

Outcome

While the HSE raised concerns about the actions of the private hospital in this case, the HSE agreed that John and his family should not have to bear the financial burden of mistakes made in handling this case. The HSE agreed to fund John’s treatment at the private hospital on the basis of the CAMHS Team’s involvement in the care plan. In addition, the HSE made a commitment that the CAMHS Team would liaise with the family and assist in John’s transition home following discharge from the hospital.

Emily was a teenage girl awaiting treatment for recurring ear and throat infections in a local hospital. Her condition became more chronic and more serious due to the lack of treatment and her hearing was severely compromised. She had also developed stomach problems due to antibiotic overuse in treating constant ear and throat infections. The HSE had national targets set by the National Treatment Purchase Fund (NTPF) that no new patient was to wait longer than one year for an out-patient Consultant
appointment. At the time of the complaint Emily had been waiting for over two years. Emily eventually received treatment two years and 11 months after her original referral, nine months after her initial Consultant’s appointment and five months after she was assessed by the Consultant. She had grommets fitted in both ears and a tonsillectomy and her hearing improved considerably following the surgery.

Actions by OCO

The OCO undertook an investigation as Emily was adversely affected by the administrative actions of the HSE. These actions relate specifically to the lack of planning that occurred in relation to meeting the national waiting list targets and the absence of clear care pathways following her assessment that contributed to a delay in her treatment. These actions resulted in extended waiting periods for assessment in particular.

Further, we found that Emily may have been adversely affected by the lack of information provided to her mother in respect of the Cross Border Initiative (C B D), thereby denying Emily’s parent the opportunity to consider, in a fully informed way, treatment for their daughter abroad.

Outcome

The hospital in question has advised that it is working closely with the Hospital Group and in line with HSE at national level in the on-going development of plans and procedures to address capacity and waiting list breaches. It is currently reducing waiting lists through outsourcing and additional theatre sessions and is developing plans to provide additional theatre and outpatient capacity. The hospital advised that in planning and delivering any current or future waiting list initiatives, no patient would be disadvantaged.

The hospital also advised that routine notification of the CBD is not in place in the hospital but the manager of the hospital will formally bring the OCO recommendation in this regard to the attention of Hospital Group for their attention and necessary action. The HSE advised that in developing strategies to manage waiting lists, an outsourcing programme for patient scheduled care has been put in place. This includes out-patient diagnostics and treatment and a review of a complete package of care. This is designed to support public hospitals address the long-term waiting lists and meet the national wait time targets. They have also informed this Office that in the current arrangement with the NTPF, the full package of care is provided for in respect of each patient referred to aprivate hospital for an outpatient appointment.

The HSE also advised that it is fully supportive of ensuring that patients and their families are properly informed of their options to avail of cross border initiatives and that the National Director of Acute Hospitals will raise the importance of promoting and marketing the CBD with all the hospital groups. The recommendations and learning from the Ombudsman’s report will be circulated to all relevant stakeholders.

We were contacted by the mother of Laura, David and Cathal in June 2016. She told us that her children were due to move to a new school and she was concerned about supports in place to address their hearing impairment. She told us that:

The two older children had been in a special class in their old school.

The parents wanted their three children to go to school together but the new school did not have a special class.

The National Council for Special Education (NCSE) had told them that the special class would not move from the old school to the new school with the children.

What we did

We contacted the NCSE who told us that they were following policy. They said that it was up to schools to apply for special classes. They told us that the children’s new school had not

applied for a special class but had applied for Low Incidence Teaching Hours (LITH) and special needs assistants (SNAs) for the children.

We contacted the school principal who confirmed this. She said that the school did not have space for a special class but that other supports were being put in place. This included LITH and SNAs who could use Irish Sign Language (ISL).

Outcome

We did not find any link between the NCSE’s or the school’s administrative actions and adverse effect on the children. Therefore, we closed the complaint. However, this complaint highlights the need for resources for children with hearing impairment. For example, ISL is not recognised as a language yet in Ireland. The only policy provision for ISL in schools is SNAs who have learned some ISL but who are neither interpreters nor teachers. We are concerned that this may have implications for children’s engagement with the curriculum and their educational outcomes and intend raising this as a policy issue in 2017.

A Social Care Manager of a residential centre contacted us on behalf of Eoin. Eoin had moved to the residential centre in 2015 because of concerns for his safety and negative influences in his previous placement. He had settled well and was hoping to stay in the area. He did not wish to return to his hometown due to his past experiences. Eoin was turning 18 in 2016. The social care manager was concerned that no aftercare arrangements had been made for Eoin for his current area, where he wanted to stay. Eoin’s Social Work team had advised that they could supply an aftercare worker and programme in the area where he lived previously, but not in his new area. The social care manager contended that the lack of aftercare services in the new area would be detrimental to Eoin and there were concerns for his safety if he had to return to the former area.

What we did

We engaged with Tusla and asked them to indicate what redress might be available and how Eoin’s best interests were taken into consideration. We stressed the immediacy of the concerns raised and encouraged local resolution.

Outcome

Tusla informed us that Eoin was appointed an aftercare worker for his new area and a plan to complete preparation tasks with the young person was now in place. As per the Leaving and Aftercare Services National Policy and Procedures Document 2011, it was envisaged that the new area aftercare service would supply the worker for advice and guidance and Eoin’s area of origin would provide the core financial support. All required documents relating to Eoin’s aftercare had been completed by his social worker, including his draft aftercare plan, preparation for leaving care documentation and an assessment of needs. The social care manager confirmed to the Office that all necessary supports had been put in place for Eoin. Following the steps taken by Tusla, the positive views expressed by Eoin and the complainant, we determined that as all parties were satisfied, further examination was not required.

Ann has been in receipt of the special needs transport grant to enable her to attend her local school. However, when her family moved house her school was no longer her nearest school. The application for a grant to maintain her current school placement was refused as it was deemed by the School Transport Appeals Board (STAB) not to be the nearest school to her new home. Her nearest school was now a Gaelscoil which was unsuitable due to her special needs and also because Ann could not speak Irish.

Furthermore her family had moved house previously and the application for special needs transport has been supported on that occasion. STAB advised that transport may be applied for on a concessionary basis. However this was deemed unsuitable for Ann due to the lack of supervision on such transport.

Ann herself wished to remain in her current school as she was happy there and had made great progress especially socially.

OCO examination of the complaint:

We examined the complaint by seeking a response from the Department of Education and Skills in relation to this case including the rationale for the decision and querying previous approval for this grant when the family had moved house before.

Outcome

The Department of Education and Skills reviewed the case and discovered that Ann’s ligibility for school transport was originally considered under the terms of the School Transport Scheme for Children with Special Educational Needs and under the terms of this scheme she was ineligible for school transport.

However, the Department determined that as Ann was attending a post primary school they felt that the criteria used to determine eligibility for school transport should reflect the same criteria used to determine eligibility under the Department’s Post Primary School Transport Scheme. Under the terms of this scheme children are eligible for school transport if they meet the distance criterion and are attending their nearest education centre. An education centre can be comprised of a number of post primary schools.

Therefore, Ann’s school was eligible and as there was no suitable transport service, the Special Transport Grant was offered to her parent to fund the cost of her private transport arrangements.

The Department also told the OCO that these eligibility criterion will apply to all cases similar to Ann.

Sean was on a school trip when another child took a photo of him and shared it via a social media App accompanied with a derogatory comment. Although the school managed the incident at the time, Sean’s parents complained to us that that the school had not given them an adequate explanation about why they were not informed immediately about the incident.

OCO examination of the complaint

We examined the complaint by seeking a response from the principal of the school about the delay, from the board of management on the policies available at the time to guide practice in the use of mobile phones and whether there was any learning for the board of management to inform any future such events. We found that the school had provided a rationale and apology to Sean’s parents about the delay. While we found no grounds of maladministration by the school we asked whether there was any learning from the incident to prevent a re-occurrence.

Outcome

• The board of management revised their mobile phone policy and agreed to review
• it annually.
• The school, with the cooperation of the Parents’ Council, arranged an open lecture
• for parents on internet safety.
• All parents now sign agreement forms acknowledging that mobile phones and digital
• cameras are not permitted on school tours.
• The board of management introduced new procedures for teachers in charge of
• school trips on managing such incidents.

We received complaints concerning the length of time that four families had been waiting for social housing in the same local authority area. The complaints were made on behalf of nine children (one family had four children, one had three and two had one child each).

• Two complaints related primarily to the local authority’s decision to defer the family’s application because of parental antisocial behaviour.
• Two complaints related to children with a disability. One family was waiting for a house while the other was waiting for adaptations to their house.

What we did

We met the local authority and asked them to explain how it:

• Operates its allocation scheme and prioritises applications;
• Makes decisions regarding the deferral of applications;
• Considers and balances children’s needs when making decisions about housing allocation;
• Communicates with families.

Allocation scheme and prioritisation

The local authority told us that its allocation scheme and prioritisation criteria are set out in the Housing Act, which sets the first category of need as homelessness. If families are classed as homeless they do not get additional priority if a child has a disability. The local authority told us that one of the families with a child with a disability had been housed, while planning for the necessary adaptations for the other were at an advanced stage.

They also told us that the families had been waiting so long because the children’s parents had refused other offers of housing.

Deferrals

The local authority told us that staff members make decisions about applicants’ risk of antisocial behaviour or offending based on the severity and frequency of prior behaviour. The local authority acknowledged that its use of hotels as emergency accommodation for families with children was not ideal but it did not have any homeless units for them considering children’s needs

The local authority stated that children’s needs are considered on a case by case basis but the need to do this is not explicit in housing legislation. The local authority advised that it is represented by junior staff on the Children and Young People’s Service Committee (CYPSC). We advised that CYPSCs are a useful forum where children’s issues can be discussed by the local authority with other key stakeholders in the area.

Communication with families

The local authority advised that it communicated with the applicants regularly. However, a parent told us that the local authority had phoned her to tell her that her application for adaptations to her house had been approved but she had received nothing in writing.

Outcome

Children of families who are waiting for social housing or disability adaptations experience adversity by having to stay in inappropriate emergency accommodation for lengthy periods of time or to live in a house that has not been adapted to suit their needs. However, in these cases these adverse effects were not directly due to the local authority’s administrative actions. Therefore, we did not investigate these complaints further.

However, we wrote to the local authority and advised it to:

• Develop local guidance for staff on decision-making regarding deferrals in the absence of national guidance. Concepts such as the frequency and severity of offending should be defined clearly so that decisions are consistent.
• Consider making changes to some administrative practices that did not require legislative change. For example, communicating effectively with service users and following up with written communication regarding any key decisions.
• Ensure representation at the CYPSC is at an appropriate level of seniority.

Finally, we intend to pursue a number of areas with the new Department of Housing, Community, Planning and Local Government and to highlight the need to meet the commitments set out in Better Outcomes Brighter Futures, the national children’s policy framework published by the Department of Children and Youth Affairs in 2014. We also met with Department representatives during consultations on the Rebuilding Ireland Plan outlining our concerns.

Simon, who has a progressive disability, was 10 when his mother complained to us. She contended that she had been on the local authority’s housing list for approximately seven years and had not been offered accommodation suitable to her son’s needs. She also raised concerns that, as her first language was not English, the local authority had not provided clear information on the housing application process.

What we did

We carried out an investigation into the mother’s complaint. The investigation concluded that:

• The local authority had incorrectly categorised the family’s application in terms of medical points for seven years
• The process of awarding points on medical grounds did not sufficiently take account of Simon’s condition;
• There was insufficient oversight of the medical categorisation process;
• The local authority did not sufficiently review the family’s application when professional/medical reports were submitted on Simon’s condition and needs;
• The family’s application and Simon’s needs were not included in regular meetings between the local authority and Occupational Therapy (OT) Services for seven years. This was because the family were living in one administrative area and accessing OT services in another;
• The local authority did not take adequate steps to address communication issues given that the mother’s first language is not English.

We also concluded that these actions negatively affected Simon by failing to take his condition fully into account and resulted in him living in unsuitable accommodation for more than eight years. We made a number of recommendations to the local authority to address the issues identified above.

Outcome

Simon’s family was offered specially adapted accommodation while our investigation was on-going. Further work was under-taken by the Council to address additional issues that arose with this property.

Administrative practices have been reviewed by the local authority in relation to the awarding of medical points for housing applicants. Supporting documentation in relation to housing applicants who have disability or medical needs will be brought to the attention of local authority staff and additional points may be awarded. OT Services refer relevant clients to the local authority for their needs to be raised at meetings. Council staff also advise

housing applicants that they should ask their medical team to bring their housing needs to the attention of the local authority at meetings.

The Council agreed that, where possible, a translator/interpreter will be provided for pre-planned meetings with clients whose first language is not English and a follow up letter in their native language will be provided where resources allow.

Sophie’s mother contacted us as she was concerned about the length of time her family had been on the medical priority housing transfer list given her daughter Sophie’s housing needs. She told us that:

• Sophie, aged 10 years, has a number of medical conditions affecting her mobility.
• The family were granted priority transfer on medical grounds; however, there had been no change in their position since September 2014.
• The family were also negatively impacted by anti-social behaviour in the area and Sophie was fearful and anxious as a result.

What we did

We contacted the local authority to determine the household’s current position on the transfer list. The local authority stated that the family were the highest priority on the transfer list for a 3-bedroom bungalow or a house with a downstairs bedroom. However, the local authority stated that there was no suitable property available or immediately forthcoming.

In order to diminish the impact of the delay on Sophie’s health and wellbeing, we requested that the local authority consider whether a safe temporary transfer could be arranged until a suitably adapted home could be identified for Sophie.

Outcome

Within five weeks a temporary home had been identified by the local authority. At the end of November 2016, Sophie’s family moved into this 2-bedroom bungalow, which was in their area of choice and close to Sophie’s extended family and school. The local authority has confirmed that a permanent specially adapted 3-bedroom house has been identified in the same area and will be available for the family to move into in 2017.

A family brought a complaint on behalf of their daughter, Sarah, aged seven. Sarah has hydrocephalus and other medical needs. The family had become homeless following the sale of the private accommodation they were renting. They had made their impending homelessness known to the local authority who had advised that no homeless service would be available until they presented as homeless. However, they had been advised of the supports that were available with regard to attempting to maintain their tenancy. As they were unable to remain in their rented home and unable to find an affordable alternative, the family had been living in hotel accommodation for a number of months and had spent nights in their car when hotel accommodation had not been sourced.

What we did

We contacted the local authorities concerned to seek their response and enquire as to what may be available to these families in light of Sarah’s needs. In Sarah’s case, we had concerns about the amount of time that a child who was on both the medical priority list and the homeless waiting list, was spending in hotel accommodation. We were concerned about the effect that this was having on her health, access to services and education. We also had concerns about how the case was being administered by the local authority.

Outcome

During our examination of Sarah’s case a suitable property was offered to and accepted by the family and we concluded our involvement in the case on the basis that the complaint had been resolved.

The OCO received a complaint from a mother on behalf of her children. It was explained that the family had been forced to leave their home due to serious anti-social behaviour which had culminated in an assault on the mother, witnessed by the children. Following this the Council housed the family in a hotel and granted priority to the family under the Exceptional Social Grounds Scheme. During this period the family home was broken into, damaged and much of the family’s belongings were lost due to vandalism and theft.

After four months in the hotel accommodation the Council informed the family that the house was to be refurbished and that they would then be expected to move back in. The family did not feel that this would be possible due to on-going and increased threats that they were being subjected to by those in the area. They understood that to stop the move back the Council were requesting a letter from An Garda Siochana to state that the lives of the family were in danger. While a letter from the Gardaí was provided it did not go so far as to state that the family’s lives were in danger. The mother sought to appeal the decision of the Council but expressed that it was not clear how they were expected to do
so. Frustration at the communication with the Council during this period was expressed.

The family also felt that the extended stay in hotel accommodation was having a negative effect on the family, including the children’s school attendance and extra-curricular activities, which they could no longer continue. In addition, it was stated that the children’s pet dog had to be given up. In complaining to the OCO the mother sought a delay to the proposed move to the family home as well as a long-term housing solution.

Outcome

Following a preliminary examination by the OCO the Council first agreed to delay the proposed move back to the home where the family had suffered the anti-social behaviour. Following this, the Council then approved a property for the family and subsequently provided them with the keys. The family were delighted with the outcome and felt that they would be safe and secure in the area that they moved to.

Jack was a teenager and was admitted into the care of Tulsa and placed in emergency accommodation as there was no other placement for him. He had been informed that, due to his age when being admitted into care, he would not receive aftercare services when he turned 18 years of age.

Jack told us that as a result of residing in homeless services he had nowhere to be or to go during the days. He was unhappy that he could only access his bed at certain times and that as a result he chose to spend a night wandering around the city centre rather than stay in the emergency accommodation.

OCO examination of the complaint

In their response to our preliminary examination Tusla stated that a residential placement had been sourced but there was a delay in moving Jack due to concerns about the behaviour of young people at that centre. It was regretted that another placement had not been sourced quicker and Tusla acknowledged the ‘limitations’ of the emergency accommodation placement.

Tusla also stated their view that extensive work and support with the young person had been offered but that the young person had not always engaged.

Outcome

During our preliminary examination of the complaint, a suitable placement was identified and the young person was subsequently moved out of emergency accommodation. The social work department explained that the young person was ineligible for Aftercare Services under TUSLA’s Leaving and After Care National Policy as young people are required to be in care for 12 consecutive months prior to their 18th birthday. However, in this case, the social work department successfully sought to have this qualifying criterion set aside and to provide supports to him as a young adult. The Office intends to raise concerns about this qualifying criterion more generally within our broader remit in relation to policy issues.

The Complaint

An anonymous complaint was received about James who was living in Oberstown. The complainant raised a number of serious concerns in relation to James’s self-harming behaviour and contended that there was a lack of psychiatric support and supervision being provided to him. In addition, the complainant alleged that staff were not provided with sufficient training and support to deal with the mental health needs and incidents of self-harm by the young people on the campus.

OCO Examination

The OCO conducted a preliminary examination of the complaint and sought details from Oberstown in relation to the assessment of James’s mental health and the measures being taken to meet his mental health needs. The OCO also met with James and staff members and sought their views on the matter.

A review of this information showed that James had been assessed by a psychiatrist in Oberstown and separately in hospital following admissions to A&E. He was found to have behavioural difficulties but not to have a psychiatric condition. Therapeutic intervention by the Oberstown Assessment Consultation Therapy Service (ACTS) team and increased supervision was recommended by the psychiatrists involved. At the time of the OCO’s examination the therapeutic intervention recommended in these assessments was being provided by the ACTS team in Oberstown. Support for staff was being addressed through the provision of inputs from the ACTS team and staff counselling.

However, in the course of the preliminary examination, the OCO became aware that no medical records from the hospital were contained in his medical files held by Oberstown. It is the view of the OCO that holding complete and up-to-date records is essential for the on-going treatment and care of the young people residing in Oberstown and is good administrative practice. The Office encouraged Oberstown to request the young man’s medical reports from the hospital and ensure that these are placed on his files. Further, the Office encouraged Oberstown to ensure that reports are obtained in respect of all incidents of medical care availed of in external settings while a young person is detained there under the Children Act 2001.

Outcome

Oberstown sought the medical reports of the young man’s assessments by the hospital. In addition, Oberstown introduced a standard operating practice whereby the clinical nurse manager now sources the relevant medical files from external settings so as to ensure relevant information on the young people is maintained on file.