Belfast home's smoking rules not enforced when fire that killed gran started, inquest told
A care home's smoking rules were not being properly enforced when a fire broke out in the bedroom of an 81-year-old grandmother with dementia, an inquest was told yesterday.
Kathleen Fegan died in hospital on April 11, 2012, after the fire at the Owenvale Care Home on west Belfast's Springfield Road.
It is believed she had been smoking in her room despite a policy supposed to prevent her from having unsupervised access to lighters and cigarettes.
Before her death, concerns were raised about Mrs Fegan's smoking on at least three previous occasions, including incidents where she burnt her fingers with a lighter and burn marks were found on her clothes.
Rosemary Gilbey, who worked as a senior care assistant at Owenvale, which was run at the time by the St John of God Association, told the inquest that financial mismanagement at the facility from 2010 saw standards decline to the extent that she feared someone would die.
"I began to feel standards were getting very low and I couldn't work there anymore," Ms Gilbey explained.
She also claimed that after taking a week of work, she returned to discover what she described as the abuse of some patients.
This allegedly included one woman being left in her room for a day and a half without food, and another man not being given pain medication for the same length of time.
"I finished my shift and stayed up all night," Ms Gilbey said of the stress the alleged incidents caused her.
She also claimed that staff took risks with medication and failed to carry out when requests when handing over responsibility during shifts.
The carer further claimed that while the smoking policy designed to protect residents from hurting themselves was acceptable, it was not being enforced.
The inquest heard that while staff verbally warned Mrs Fegan about the danger of smoking in her room, Ms Gilbey said this was insufficient protection for a dementia patient.
"That's simply not good enough - that's why I'm so frustrated," she added. "Communication between the staff and residents was very poor. (Dementia patients) can't process that information. Staff should have rang the care manager and family."
The smoking policy at the time for patients like Mrs Fegan dictated that they should be given individual cigarettes by staff when requested and that these should be smoked, under supervision, in a smoking area.
The inquest heard evidence that record keeping of the number of cigarettes given to Mrs Fegan was inconsistent, and it was possible she had been able to get her own supply.
Following the financial mismanagement at Owenvale, Brother Michael Newman, from the St John of God Association, was brought in as manager to address the problems. "Brother Michael said he was unhappy with standards but did nothing about it," said Ms Gilbey.
She added that although she had a good working relationship with him, his experience was not suited to addressing the scale of the problems. "He was out of the nursing environment for a long time - it was unfair to him," the carer explained.
Ms Gilbey reported her concerns, but was suspended from her job without a reference.
She later reported the issues to the Regulation and Quality Improvement Authority (RQIA), which lifted her suspension.
An RQIA report soon led to the suspension of several other senior staff members.
In January 2012, before Mrs Fegan's death in April, a new manager from the St John of God Association, Cormac Coyle, was appointed at short notice following the RQIA report.
Mr Coyle told the inquest he was aware of the staffing and morale issues.
He added there were problems with the referral process for admitting residents, judging that 10 were not suitable to be housed at Owenvale, including Mrs Fegan.
Coroner Patrick McGurgan asked Mr Coyle: "Was there not urgency for a more suitable home?"
He replied that there was a process in motion to move Mrs Fegan and that other measures such as smoke alarms that speak to residents in bedrooms, additional staffing, risk assessments and care plans had since been ordered.
Mr McGurgan questioned how staff knew Mrs Fegan had not been secretly saving up her own supply of cigarettes.
"Where staff gave out cigarettes, they would have watched her smoke them," explained Mr Coyle.
Regarding the records of cigarettes given out to Mrs Fegan, the coroner told Mr Coyle: "You can't make head nor tail of them."
Attending the inquest was Mrs Fegan's granddaughters, Nicci Reid and Terri Fegan.
At one point they chose to leave the court room as evidence was heard from a care assistant who was at Owenvale on the night of Mrs Fegan's death,
Jonathan Simpson was alerted to the fire in Mrs Fegan's room along with other staff.
Despite attempts to save her by wrapping her in wet towels and immediately calling emergency services, she later died from her injuries in the Royal Victoria Hospital.
The inquest continues.