The safeguarding system in Northern Ireland did not provide adequate protection for an elderly patient with dementia, who is considered one of the most vulnerable adults in the region.
Stanley O’Neill had not taken a shower for three months and was discovered in the act of putting a cord around his neck.
Despite the guidelines set for healthcare, the mentioned shortcomings and others were not brought to the attention of adult safeguarding investigations.
The nursing home received a negative review for not being forthcoming and honest with the family of a 79-year-old resident.
On 20 December 2021, Mr O’Neill passed away in a hospital.
The family of a patient expressed their deep distress due to several inadequacies in the care provided to him, which were revealed by an inquiry conducted by the Belfast Health Trust.
Bradley Manor Care Home expressed their sympathy and regretted to Mr O’Neill’s family in a formal statement.
The representative of the organization stated that ensuring the safety of their residents has always been their top priority. However, they admit to falling short in meeting certain high standards that are rightfully expected of them.
The adult social care sector experienced an unparalleled time during the Covid-19 pandemic, and despite not making any justifications, they were confronted with exceptional pressures and an exceedingly difficult environment.
The adult safeguarding system aims to safeguard adults who are vulnerable in the healthcare system when concerns are raised about their welfare by staff, patients, or relatives.
During an interview with BBC News NI, the healthcare watchdog of Northern Ireland expressed that the needs of vulnerable adults in the region were not being met.
Sophie O’Neill had a strong bond with her grandfather and viewed him as the foundation of her family, referring to him as "our rock".
After Stanley O’Neill was diagnosed with dementia, his life took a significant turn.
The situation at home became too difficult to handle and as a result, the person had to stay in multiple nursing homes and hospitals.
Mr. O’Neill moved into Bradley Manor, located in north Belfast, in January 2021 while the pandemic was ongoing. The Belfast Health Trust had placed him there after he had been admitted to the hospital.
Sophie, the granddaughter, mentioned that her family started to take notice of various incidents that were causing concern.
The woman reported that there were two falls that occurred during the night that were not seen by anyone. This made her concerned. However, she later realized that the call bell in the man’s room had been taken away.
I found out weeks later that the information about someone wrapping a cord around their neck was only given to us after I asked the staff. They said they had seen it and removed it.
Sophie expressed her surprise and confusion at the delay in informing the family of the person in question. She was completely taken aback by this delay and did not understand the reason behind it
I experienced incidences related to ensuring the safety of individuals, but no measures were taken to address them.
Sophie became aware of the term "safeguarding referral" for the first time when her grandfather was admitted to the hospital in December 2021.
Sophie discovered that Mr. O’Neill was not reacting in his room at Bradley Manor and he was later admitted to the Mater Hospital in Belfast.
Sophie reported that upon her arrival at the hospital, a member of the hospital staff expressed worry about her grandad’s condition.
According to the hospital staff, the person’s dental hygiene was the most terrible they had encountered. As a result, the hospital began considering the possibility of referring the individual for adult safeguarding.
‚Failure in healthcare‘
A person named Mr. O’Neill was hospitalized on December 6th and passed away after 14 days.
The family of the person who was referred to adult safeguarding did not receive any notification through a phone call until two days after the person had passed away. The investigators who were handling the case were not informed about the
The matter has been forwarded to the coroner, who will ultimately decide the formal reason for the person’s passing.
According to Sophie, the main purpose of a safeguarding referral is to ensure the protection of an individual. However, in the case of her grandfather, the referral came in too late to provide any sort of protection
After some time, the Belfast Health Trust looked into Mr O’Neill’s situation as a significant negative occurrence.
A severe negative occurrence is characterized as any happening or situation that resulted or could have resulted in significant unintended or unforeseen injury to patients.
It is required to submit investigation reports within a time frame of 12 weeks starting from the day the incident was reported.
In April 2023, a preliminary report was sent to his relatives. The report discovered:
According to the report, everyone involved in Mr. O’Neill’s care was found to have made mistakes.
After reviewing his situation, health and social care personnel have received educational materials on the appropriate approach for addressing adult safeguarding concerns.
In Northern Ireland, there has been a rise in the number of referrals made for adult safeguarding in recent times, increasing from 4,778 in 2019 to 6,897 in 2021. This indicates that the current system may not be effective in fulfilling
According to the Department of Health, the rise in reports of adult abuse could be due to increased public knowledge and awareness about the issue.
Mr. O’Neill’s case has exposed certain shortcomings, coinciding with the Northern Ireland Public Services Ombudsman (Nipso) expressing doubts about the effectiveness of the adult safeguarding system in Northern Ireland.
According to the ombudsman Margaret Kelly, based on several instances that have been brought to her attention, it appears evident that our current system for protecting adults is inadequate.
Many times, families have to raise concerns about the quality of healthcare provided by the staff, which shouldn’t be the case.
During the past few years, the ombudsman’s office has handled eight cases related to nursing and care homes. Out of these eight cases, adult safeguarding was a concern in seven of them.
The instances brought before the ombudsman were
Ms. Kelly expressed her disappointment that although these cases demonstrate significant shortcomings, she believes they only represent a small portion of a much larger issue.
According to her, Northern Ireland is at risk of lagging behind in safeguarding its most susceptible population.
Even though several health ministers have promised to implement it, Northern Ireland is the only area in both the UK and Ireland that does not have its own adult safeguarding laws.
The Department of Health has acknowledged that the current legislation has some shortcomings and plans to introduce a new adult safeguarding bill once the Northern Ireland Executive and Assembly are back in session.
According to Bradley Manor, their top priority is the welfare of their residents. They have already made several adjustments in response to the deficiencies highlighted in the report.
The trust responsible for overseeing the care home in Belfast has stated that they have increased their level of monitoring and have put measures in place to improve the quality and safety of
Sophie shared her thoughts on her grandfather’s situation, stating that if other families find themselves in a similar position, she would encourage them to speak up for their loved ones and not let fear stop them.
The concern at hand is the program titled "Failed In Care" which is only available for viewing on BBC iPlayer in
Stanley’s story revolves around a flawed safeguarding system and a family’s quest for finding answers.
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