It"s time we all learned to really accept responsibility

The report of the Ombudsman into the neglect that saw the health of an 88 year old stroke victim deteriorate rapidly after her daughter booked her in for one week"s respite care at St. Mary"s Hospital in Mullingar, makes shocking reading.For two days, the woman received basically no fluids and no food, according to the report, released on Monday.The woman"s daughter, who had cared for the elderly stroke victim for five years, was horrified to find - three days into the week that her mother was to be cared for at St. Mary"s - that she was dehydrated, had a urinary infection, and had developed bedsores.The report makes shocking reading: a catalogue of mistakes, failures, and oversights - and then a reluctance to meet openly with the woman"s daughter to discuss the matter, which was why the daughter asked the Ombudsman to take up the case.In fairness to the hospital, there was an admission early on that standards of care had fallen short of what they should be, and they have been implementing the recommendations made by the Ombudsman.However, the report makes distressing reading, and the woman"s daughter - almost three years on from the death of her mother, is still furious at what happened during those three days at St. Mary"s. She wants, she says, that no-one else should suffer the same fate.In general, while there are criticisms of the healthcare system in this country, there is widespread respect and admiration for medical staff, and few criticisms of the standards of care. That is why it is so shocking to find how easily the St. Mary"s problem came about, and it is clear from the Ombudsman"s report that there are some discrepancies in the explanations given by staff who were involved in the problem.It is indeed fair to say that we all make mistakes in our working lives. The difference is that there are few fields where these can have such immediate life-threatening effects. A shop assistant can hand out the wrong change; a journalist can libel someone; a lawyer can bungle a document; a banker can lend money to a bad-risk customer. Most of these problems can be remedied through litigation.But people who have, quite literally, the lives of other people in their hands every day - such as pilots, train drivers, bus drivers, teachers, and medical personnel cannot afford to make mistakes.It may not be fair that these people carry a greater burden of responsibility than the rest of us, but that is the way things are. And it"s why there are such checks and controls in place in all these fields. It"s a way of sharing the responsibility; and of making sure people with roles of responsibility approach those roles conscious of the extent and seriousness of their responsibilities.At St. Mary"s, the failures came on many fronts: it appeared there was no-one at the top checking what was being done, and no-one was being called to account when it emerged that this unfortunately elderly lady had spent almost two days with virtually no food nor fluids. The fact that staff were aware the elderly woman had feeding difficulties, and that she needed, consequently, to be seen by a Speech and Language Therapist who could best determine how she should be fed, is made clear in the document. But what"s also made clear is that efforts to contact the Speech Therapist were half-hearted.Staff had been given a full outline of what this patient"s needs and routines were - and the daughter left her phone number asking that she be contacted with any problems. It appears no-one took charge of implementing that routine, and no-one saw fit to inform the woman of the deterioration of her mother"s condition. That was probably because no-one saw it as their responsibility.There is always a temptation when a problem arises, to try and stay 'under the radar', and if asked about it, to declare ignorance of the problem.But it should always be remembered that it was a diligent nurse who lifted the lid on the extraordinary rate of hysterectomies occurring among patients of Dr. Michael Neary in Drogheda, and all medical staff have a responsibility to ensure that no mistake, malpractice or ineptitude slip under the radar.Not while people"slives and health areat risk.