Whistleblower devastated at findings of report into 24 covid deaths in nursing home 

With only a summary of the investigation into nursing home deaths published, Mallow woman Margo Hannon remains doubtful reform can follow. 

The whistleblower who revealed tragic failures at a Dublin nursing home in 2020 said she is “devastated” by summary investigation findings published by the HSE.

Some 24 people died from covid-19 at St Mary’s Hospital, Phoenix Park that year, according to HSE records. This report shows 22 died during an initial outbreak from March to April.

However, with only a summary of the investigation published, Mallow woman Margo Hannon remains doubtful reform can follow. 

“I feel devastated, to be honest. It is not the full 500-page redacted St Mary’s Hospital investigation report we expected, paid for by taxpayers,” she said.

“I am thinking about families affected and heroic frontline staff at this difficult time.” 

Ms Hannon, then a healthcare assistant and now reluctantly resigned, made a protected disclosure under 12 headings including failures around infection control, PPE, and contact with relatives.

An investigation by Acrux Consulting was completed in May 2022 but only the summary has been published.

Her growing concern now is the limited potential she sees for reforms.

“I fear success by the HSE will be determined by the extent to which the status quo can be maintained and reports like this one effectively ignored while giving off the veneer of doing something,” she said.

“The 36 pages (summary) does not reflect a forensic examination of my protected disclosure. Instead, it lacks detail and recommendations for future learning.” 

She feels now her experience “reinforces the need for a national human rights-led public inquiry” dedicated to the nursing homes crisis.

This is a call also from advocacy group Care Champions who have supported Ms Hannon.

“For the three-year ‘expedient’ duration of the St Mary’s Hospital investigation, I felt like I was the one being investigated and I had to consciously remind myself that the evidence speaks for itself,” she said.

She urged potential whistleblowers not to rely solely on protected disclosures.

“(You should make) a bit of noise about it as well through relevant support bodies, advocacy agencies, compassionate, passionate politicians,” she said.

It remains to be seen, she said, what influence families’ concerns will have.

“I feel my voice and that of families was lost in the significant delays in getting to the preliminary findings and the executive summary findings,” she said.

Findings

The investigation found her concerns around failure to enforce social distancing guidelines “well-founded” and breaches should not have been tolerated.

However, Acrux Consulting's remit did not require recommendations, and it expects the summary to ensure “improving, learning or other actions can be taken”.

An HSE spokesman said: “During 2020, sadly there were 24 covid-19 related deaths of residents within St Mary’s Hospital. Our sympathies are with their families.” 

He said full reports following protected disclosures investigations “are not generally published”. 

He added: “It is HSE practice to publish comprehensive executive summaries to balance our obligations to all parties. Other nursing homes can fully benefit as all findings are contained in the comprehensive executive summary.” 

The document, published March 2, is marked “Executive Summary of report dated May 28, 2022”.

He said: “The HSE understands the complexity of the work and other factors such as the ongoing pandemic meant the investigation team’s work took longer than would otherwise be the case.” 

Ms Hannon raised concerns at the time, but says: “(I) felt completely ignored.” 

The report found failure to isolate residents after March 29 “may have put some residents at risk” and her emailed concern was not appropriately responded to.

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In another example, she said: “My concern was in relation to being not allowed to wear a mask for patients coughing and symptomatic with covid. Instead we were told to ‘take a step back.’ This point was not addressed.” 

“This was not an easy time for anybody,” she stressed. 

“I am disappointed the executive summary did not uphold my personal grievance in being sent home for ‘stressing management staff’ with my email concerns. That was the hardest part of raising concerns, that I was not allowed to work in a time of crisis and suffering.” 

The report acknowledges ongoing learning among staff at a time of great crisis and concern around PPE access.

It did not uphold concerns around inappropriate end-of-life care provided to residents.