System Analysis Investigation - 1. Request, Falsehoods and an attempted Whitewash
Firstly, I would like to state to all those who write policy documents for the Health Service Executive (HSE) in Ireland, they are not worth the paper they are written on, the policies are not followed and there is no accountability. The policies appear to be official and in line with legislative and regulatory requirements but in fact are worthless, because what has been promised will not be done. It is all just hot air, written to impress, with no real value or meaning. A complete waste of time and money, paid for by the Irish taxpayer!
A solicitor advised our family that the Health Service Executive (HSE) are required to carry out a Systems Analysis Investigation due to the circumstances of our late father’s death at St Luke’s General Hospital, Kilkenny.
The HSE has an Incident Management Framework (IMF) 2020 policy which states;
“Primary responsibility and accountability for the effective management of incidents remains with the organisational level at which the incident occurs.”
The HSE defines a System Analysis Investigation as follows;
“A structured process that aims to identify what happened, how and why it happened, what can be done to reduce the risk of recurrence and make services safer. The process applied considers how all parts of the healthcare system may have interacted and contributed to the outcome. In considering an incident in this manner it is more likely that the findings identified will lead to actions required to address any system issues which may have existed.”
The HSE sets out the following timeframe for completion of System Analysis Investigation;
“The HSE has in place a timeframe of 125 days for the completion of the review i.e. from date of occurrence of the incident”
The HSE sets out the following categories of incidents;
The HSE states the following in regard to System Analysis Investigation;
The HSE also states the following in regard to System Analysis Investigation;
“Due to the level of harm incurred, Category 1 and Category 2 incidents require preliminary assessment to support a formal decision being taken in relation to review. Detail of the assessment and decision-making process must be recorded using the Preliminary Assessment Form.”
The HSE is a public service provider and St Luke’s General Hospital, Kilkenny is a public service hospital located in Kilkenny, Co Kilkenny, Ireland and is managed by the Ireland East Hospital Group (IEHG) comprising 12 public service hospitals.
Due to the circumstances of our late father’s death at that hospital, my sister requested the management of St Luke’s General Hospital, Kilkenny to carry out a System Analysis Investigation in order to get to the root cause. She initially requested this on 28th February 2023. It was necessary for her to request this on all of the following dates as her request was repeatedly ignored by the HSE;
It was subsequently necessary for our family to follow a separate process regarding the request for a System Analysis Investigation which involved Freedom of Information requests. I wrote about this in my post titled: “Broken Trust 001 - Complaint to the Health Service Executive (HSE) via the General Manager of St Luke’s General Hospital, Kilkenny dated 27th February 2023” and mentioned that to the date of publishing that post, 18th November 2024 this matter had not been concluded.
It was not concluded as I had submitted the matter to the Ombudsman on 14th June 2024. It appears that the Ombudsman did not investigate the matter at all, as on 22nd November 2024 just five days after I published my Substack “Broken Trust 001” where I wrote about this and more than five months since receipt, the Ombudsman suddenly and unexpectedly closed the case by writing to me to state: “where the substantive issue of complaint falls outside our remit, we cannot investigate anything relating to that matter. Consequently, your complaint falls outside our remit and I will be closing the file now.”
The reasons given by the Ombudsman to close the file were not valid, as the substantive issue of my complaint did not fall outside the remit of the Ombudsman.
I do not believe this was a coincidence.
As my sister’s requests were being ignored, it was necessary for me to write by email on 19th June 2023 to Ms Niamh Lacey, General Manager to ask if a System Analysis Investigation would be carried out. I copied in Dr Philip Crowley, National Director, HSE Head Office into my email:
I did not receive a response to my email dated 19th June 2023 and therefore, it was necessary for me to write by email once again on 8th July 2023 and this time in addition to Dr Philip Crowley, National Director, HSE Head Office, I also copied in the Director of Nursing, Prof Garry Courtney the Clinical Director, the Patient Liaison Officer, the Ireland East Hospital Group (IEHG) and the HSE Communications department:
On 10th July 2023 I received the following email from the General Manager’s Office with attached letter:
On 10th July 2023 my sister received a similar letter from Ms Niamh Lacey, General Manager to state that she had “requested a Preliminary Assessment be carried out in line with the HSE Incident Management Framework, from here it will then be discussed at our Serious Incident Management Team meeting as part of the HSE incident Management Framework to determine whether a further review is required.”
However, why was it necessary for us to need to contact so many people before Ms Niamh Lacey responded?
Additionally, the timeframe for completion of a System Analysis Investigation as per the HSE policy had been completely ignored.
Therefore, it was necessary for me to respond to Ms Niamh Lacey, General Manager by email on the same day, 10th July 2023 with copy to Dr Philip Crowley, National Director, HSE Head Office, the HSE Communications department and others:
On 13th July 2023 my sister responded to the email she received from Ms Niamh Lacey, General Manager on 10th July 2023 to ask in particular WHY a Preliminary Assessment had not already been done?
On 14th July 2023 my sister received the following email response from Ms Niamh Lacey, General Manager to state:
On the same day, 14th July 2023 I received the following email response from Ms Niamh Lacey, General Manager and I note that she copied in Dr Philip Crowley, National Director, HSE Head Office and the HSE Communication’s department. I also note that she states that the reason for her non-consistence approach is “as a direct result of not having staff within this Department and my commencement of the new role”. Therefore, following the previous General Manager, Ms Anne Slattery leaving her employment suddenly and unexpectedly in April 2023 (as I received an email notification that her HSE email address was “no longer being monitored” on 19th April 2023), Ms Niamh Lacey was then appointed as General Manager. However, it is clear that she is not functioning appropriately and has no staff!
On 16th July 2023 I sent the following response to Ms Niamh Lacey, General Manager by email with copy to Prof Garry Courtney the Clinical Director, St Luke’s General Hospital, Kilkenny and others to point out their failings and in particular the following:
On 28th July 2023 I received the following email with attached shocking letter directly from Ms Niamh Lacey, General Manager where she copied in Dr Philip Crowley, National Director, HSE Head Office and the HSE Communication’s department showing their involvement in the decision to attempt to cover-up and whitewash the wrongdoing and criminal acts of staff employed by the HSE:
Ms Niamh Lacey, General Manager stated in the letter above “if you are dissatisfied with the outcome of the investigation, you may request a review to the Office of the Ombudsman”.
However, as mentioned earlier, when I took this complaint to the Ombudsman, they shut it down!
It appears that the Ombudsman did not investigate the matter at all, as on 22nd November 2024 just five days after I published my Substack “Broken Trust 001” where I wrote about this and more than five months since receipt, the Ombudsman suddenly and unexpectedly closed the case by writing to me to state: “where the substantive issue of complaint falls outside our remit, we cannot investigate anything relating to that matter. Consequently, your complaint falls outside our remit and I will be closing the file now.”
The reasons given by the Ombudsman to close the file were not valid, as the substantive issue of my complaint did not fall outside the remit of the Ombudsman.
I do not believe this was a coincidence.
On the same day, 28th July 2023 my sister received an email from Ms Niamh Lacey, General Manager with the same shocking letter dated 27th July 2023 titled: 27-7-2023 Reply XX Systems analysis request.
The letter to us both stated that a System Analysis Investigation had been requested on 08.07.2023. This is a falsehood as the request for a System Analysis Investigation was first made on 28th February 2023 and numerous times thereafter.
Ms Niamh Lacey, General Manager also wrote a falsehood regarding the documentation used in order to assist with decision making where she stated:
This falsehood was revealed through further correspondence.
The shocking letter also stated the following “your concerns are being dealt with through the complaints process”
The complaint process Ms Niamh Lacey, General Manager was referring to was the investigation she passed to Ms Susan Tynan a Clerical Officer worker who eventually responded on 4th October 2023 to my sister’s serious complaint dated 27th February 2023 – see my posts titled: “Broken Trust 002 – Response to Complaint to the Health Service Executive (HSE) via the General Manager of St Luke’s General Hospital, Kilkenny dated 27th February 2023” and “Broken Trust 003 – Review of Complaint to the Health Service Executive (HSE) via the General Manager of St Luke’s General Hospital, Kilkenny dated 27th February 2023”
Where;
Then, Ms Barbara Smyth did NOT carry out any proper investigation on appeal and it is evident that she has acted in breach of the Health Act 2004 (Complaints) Regulations 2006.
There appears to be no accountability for staff of the HSE!
On 28th July 2023 in response to the shocking letter, I sent the following email to Ms Niamh Lacey, General Manager with copy to others:
In response to the same shocking letter received by my sister, she sent a similar email on 1st August 2023 to Ms Niamh Lacey, General Manager with a copy to: Ms Fiona McEvoy/Ms Helen Bulter, Director of Nursing, Professor Garry Courtney, Clinical Director, Ms Alison Mulloney, Patient Liaison Officer and Dr Philip Crowley, National Director, Strategy and Research, HSE Head Office to ask for a copy of the following:
On 12th August 2023 as we had not received any response from Ms Niamh Lacey, General Manager to our request for the documents, it was therefore, necessary for me to send an email again on 14th August 2023. Additionally, it was necessary for me to note to Ms Niamh Lacey to ask her to NOT delete some of my emails from the chain which contain important factual detail, as she had done this in a previous response - she deleted my email which contained in particular the following facts:
Later that same day, 14th August 2023, I received the following acknowledgement from Ms Susan Tynan, Complaints Officer, Consumer Affairs Department, St Luke’s General Hospital, Kilkenny:
However, following receipt of the above, it was necessary for me to send a further email to Ms Niamh Lacey, General Manager later the same day, 14th August 2023 as not all correspondence had been acknowledged and it was clear to me that the HSE was deliberately withholding information from our family. Additionally, I requested a copy of the minutes of the meeting held by the Serious Incident Management Team (SIMT) on Monday, 24.07.2023 where this matter was reviewed and discussed:
On 15th August 2023 I received the following email from Ms Susan Tynan, Complaints Officer, Consumer Affairs Department, St Luke’s General Hospital, Kilkenny with attached letter from Mr Declan Kelly, General Services Manager and FOI Decision Maker:
The HSE were now treating my request for the documents under Freedom of Information (FOI) when I had NOT asked for the documents through FOI. The letter dated 15th August 2023 from Mr Declan Kelly, General Services Manager and FOI Decision Maker stated the following:
This confirmed that Ms Niamh Lacey, General Manager had stated the following falsehood in her shocking letter dated 27th July 2023 written to both my sister and myself and sent separately to us by email on 28th July 2023:
Mr Declan Kelly, General Services Manager and FOI Decision Maker provided a heavily redacted document titled: “Preliminary Assessment Form - SAI - Mtg 24.07.2023” attached to his letter dated 15th August 2023. I now know that the document was heavily redacted through receipt of my late father’s medical records obtained through a solicitor.
What Mr Declan Kelly as FOI Decision Maker (employed by St Luke’s General Hospital, Kilkenny) had done was to provide a Preliminary Assessment Form to me through FOI (which I did not ask for through FOI) with limited detail and almost five pages left blank as if no detail had been entered in the first place. The blank pages were not showing as redactions, just blank.
I now know the real reason the HSE provided the Preliminary Assessment Form document to me under FOI, when I had not asked for it through FOI. The HSE wanted to hide the details completed in the Preliminary Assessment Form through redaction, as to provide the unredacted form would provide evidence that a proper investigation had NOT been carried out and falsehoods were stated throughout the completed form.
This became clear on obtaining the unredacted Preliminary Assessment Form contained within our late father’s medical records which the HSE tried to prevent us from obtaining, until we instructed a solicitor to obtain this on our behalf – see my post titled: “The HSE and OIC Denied Next-of-Kin Access to Late Father’s Medical Records”
I have found some of the people employed by the HSE to be working for the dark side.