System Analysis Investigation - 19. The OIC - Decision - Serious Incidents - Hiding the Numbers!

The state of being hidden.

Case Number OIC-143166-P2M8L8 submitted to the Office of the Information Commissioner (OIC) on 17^th October 2023 was my request for the following;

See my post titled: “System Analysis Investigation - 16. The OIC - Number of Serious Incidents at St Luke's General Hospital, Kilkenny”

I received the following email and attached letter dated 24^th January 2024 from Ms Rachael Lord, Investigator, OIC with the subject heading; “Summary of material issues to applicant.pdf”. She stated the attached letter of the same name was “a summary of material issues raised by the HSE” and asked for a response no later than 7^th February 2024;

OIC LETTER DATED 24^th JANUARY 2024 - “Summary of material issues to applicant.pdf”;

I responded to Ms Rachael Lord on 31^st January 2024 by email (see below) and attached my second letter of submission along with a copy of an Inspection Report which was written following an unannounced inspection carried out by the Health Information and Quality Authority (HIQA) at St Luke’s General Hospital Kilkenny on 26^th January 2023, shortly after the death of our father at that hospital. The inspection judged the hospital to be only “Partially compliant” in all areas. This was reported in the local news by the Kilkenny People on 26^th July 2023 which was six months after the unannounced inspection – see my post titled: “The Covid Ward”

Ms Anne Slattery was the General Manager at the time of our father’s admission and death at that hospital and she held that role during the unannounced inspection by the HIQA. She left the employment of St Luke’s General Hospital, Kilkenny in May 2023 just four months following our father’s death and the unannounced inspection, which I do not believe to be a coincidence and in my opinion, this is strongly correlated.

My second letter of submission to Ms Rachael Lord dated 31^st January 2024, in particular stated the following points;

And;

And;

And;

And;

And;

And;

MY RESPONSE (SECOND LETTER OF SUBMISSION) DATED 31^st JANUARY 2024;

Ms Rachael Lord had stated the following in her letter dated 29^th January 2024 regarding my separate appeal; Case Number OIC-142881-Z0N2V5 which was crudely shut down by Mr Stephen Rafferty, Senior Investigator on 2^nd February 2024, where she crosses over to mention this appeal; Case Number OIC-143166-P2M8L8. This implies that she had already predetermined the outcome of this appeal; Case Number OIC-143166-P2M8L8, BEFORE receiving my second submission letter regarding this appeal two days later on 31^st January 2024;

How could she predetermine the outcome BEFORE having all of the facts?

Ms Rachael Lord did not contact me regarding any of the points I raised in my above submission letter dated 31^st January 2024. Rather, she moved straight to a decision where without any prior contact with me, more than three weeks later on 26^th February 2024, she sent me an email named “Notice of decision to applicant” with an attached Decision;

The Decision:

In my opinion, the reason Ms Rachael Lord issued a decision on this matter at all was due to the fact that I had raised the following issue (see below) within my letter to the OIC dated 30^th January 2024. Following this, Mr Stephen Rafferty, Senior Investigator issued a “Notice of discontinuance” thus, he ‘shut down’ my appeal for Case Number OIC-142881-Z0N2V5 and took my right to challenge his decision away! – see my post titled: “System Analysis Investigation - 18. The OIC – Crudely Shut Down!”;

It is my opinion, that following my raising the above issue on 30^th January 2024, rather than shut down this appeal, the OIC instead relied on misdirecting matters. This is evident under the heading of “Scope of Review” in the above ‘Decision’, where Ms Rachael Lord states the following;

It is undeniable that the above statement by Ms Rachael Lord is a misdirection. The factual position is that I did request the total number of incidents (patients) discussed in my original request to the HSE dated 30^th August 2023 as follows:

I also requested the total number of incidences (patients) in my application for review to the OIC (referred to as “this Office” by Ms Rachael Lord) dated 17^th October 2023 as follows;

Further evidence of misdirection can be seen where Ms Rachael Lord makes the following statement in her letter to me dated 24^th January 2024 thus, confirming that I had asked for the number of incidents (patients) discussed at the meeting in my application for review to the OIC dated 17^th October 2023;

Additionally, I referred to the total number of incidences (patients) in my submission letter addressed to the OIC dated 31^st January 2024 as follows;

It is most concerning that the OIC are publishing misdirection within their Decisions!

Under the heading of “Preliminary Matters” in the above ‘Decision’, Ms Rachael Lord states the following;

It is most interesting that Ms Rachael Lord states the following above “during the course of these requests the applicant has been established as her late father’s next of kin, and on that basis has a right to access his personal data in the records requested as part of this request.” Whereas, on 26^th June 2023 the OIC denied my sister access to our late father’s HSE medical records stating the following “It is important to note that the fact of an FOI requester being the next of kin does not mean that the requestor is automatically entitled to the records of the deceased person” - See my post titled: “The HSE and OIC Denied Next-of-Kin Access to Late Father's Medical Records”;

It is most concerning that the OIC are inconsistent and publishing contradictory statements within their Decisions!

In the above ‘Decision’ under the heading of “Preliminary Matters” Ms Rachael Lord states the following “This is notwithstanding the fact that the same information in the record in question was already released to the applicant by virtue of a separate request.” In my opinion, Ms Rachael Lord once again is using misdirection, as the data I referred to (see below) was revealed for the first time through receipt of the minutes of the SIMT meeting dated 03.07.2023, where the personal data of my late father was included. However, personal data had not been requested. It appears that the OIC chose not to challenge the HSE on this matter. The data that had been released to me by virtue of a separate FOI request was within the minutes of a different meeting held by the hospital’s Serious Incident Management Team (SIMT) on Monday, 24.07.2023. See my post titled; “System Analysis Investigation - 18. The OIC – Crudely Shut Down!”

However, the release of the data in that instance was highly beneficial as it provided facts that were missing. It was through the release of my late father’s personal data within the minutes of the SIMT meeting dated 03.07.2023 which revealed that the SIMT had previously discussed our late father, where the following people found “NO incident occurred – Preliminary assessment to be completed”. They decided that no incident occurred BEFORE any investigation had taken place and Part A of the Preliminary Assessment Form had NOT been completed. In my opinion, this is evidence of an attempted cover-up! See my post titled: “System Analysis Investigation - 13. REVEALED Decision Made BEFORE Preliminary Assessment Investigation!”;

Under the heading of “Submissions from the HSE” in the above ‘Decision’, Ms Rachael Lord states the following thus, confirming that no SIMT meeting took place in February 2023. Therefore, I have established this fact. If the HSE create a false record to state that my late father was discussed at a meeting held in February 2023, the false data will be visible and challenged;

Under the heading of “My Analysis” in the above ‘Decision’, Ms Rachael Lord states the following thus, further confirming that no SIMT meeting took place in February 2023;

Under the heading of “My Analysis” in the above ‘Decision’, Ms Rachael Lord states the following;

In my opinion, Ms Rachael Lord has misdirected the following fact which I had explained to her in my submission letter of application for this appeal dated 17^th October 2023;

Ms Rachael Lord states the following regarding the above “I would not consider this to be a ‘reasonable step’”. However, she does not give a valid reason as to why she holds that opinion!

In my opinion, there is no valid reason why this could not have been done!

My late father died on 5^th January 2023 at that hospital and Senior Management were notified in good time before my father’s death of the serious failings in safety and standard of care that were taking place at that hospital.

Through this Freedom of Information (FOI) request, I have established as fact that there were numerous opportunities where the Serious Incident Management Team (SIMT) could have investigated the hospital’s serious failings in safety and standard of care. Numerous SIMT meetings were held where this matter could have been investigated within appropriate timescales.

However, warnings were ignored by the same people who were tasked with managing the hospital when the serious failings in safety and standard of care occurred. It cannot be denied that those same people were the core members of the Serious Incident Management Team (SIMT) who decide on what matters to investigate!

It is evident that these people chose not to investigate this matter following the correct guidelines and appropriate timescales, as it would reveal that they had breached their legal duty of care, where a reasonable standard of care had not been met. In my opinion, they decided instead to give this matter lip service and this was only after much persistence from my late father’s family, who unfortunately, had to witness the serious failings in safety and standard of care carried out at that hospital through the loss of our dear father.

Are these people not aware that they have a duty of care to provide a reasonable standard of care to their patients and to act in ways to protect their safety?

Are they not aware that they are answerable to both their patients and to the public at large?

Are these people under the impression that they will not be held to account for their actions and omissions?

Do these people wrongly believe they cannot be criminally prosecuted?

In my opinion, it appears that both the HSE and the OIC are intent on hiding the number of patients that the HSE and St Luke’s General Hospital, Kilkenny in particular, have harmed, put in serious danger and have died as a result of their serious failings!

The anonymised OIC Decision report Case Number; OIC-143166-P2M8L8 can be viewed on the OIC public access portal at the following link:

https://www.oic.ie/en/

When open click on the word Decisions at the top of the page:

The following page will display. Enter the Case Number OIC-143166-P2M8L8 in the search box and click the Search tab:

The result will show as follows:

Click on the header showing online to access the Decision report:

The Decision report will open as follows: