Press Releases

Main features of the Annual Report:

Chapter 1: Introduction

In her Introduction, the Ombudsman reports, inter alia, on a significant development for her Office which is the expected publication and enactment of the Ombudsman (Amendment Bill). The proposed Bill, which she understands will be published shortly by the Minister for Finance, provides for an extension of the Ombudsman's jurisdiction to a wider range of public bodies for example, FÁS, the Vocational Education Committees and the Universities and other third level colleges. The Bill will also include an important new provision which will enable the Ombudsman to state a case to the High Court on any question of law arising from her examination of a complaint. The Bill will also make provision for the protection of the term Ombudsman.

The Ombudsman welcomes these proposals which will represent a further significant advance in the accountability of state agencies and addresses at least in part, some of the concerns which she raised in her previous annual report about the wide range of public bodies, many of which had significant interactions with the public, which were not subject to independent scrutiny by the Ombudsman. However, despite this welcome development, she does express her concerns that the proposed Bill will not extend her remit to complaints regarding decisions in relation to immigration and asylum matters adding that this lacuna in her jurisdiction leaves her Office significantly out of line with other ombudsman offices abroad.

Chapter Two : "Resolving Complaints and Improving Public Administration"

In Chapter 2 the Ombudsman shows how her Office improves public administration generally through the resolution of individual complaints which, in turn, uncover wider systemic weaknesses. She also encourages public bodies to learn from the mistakes of other public bodies to improve their own services. In this regard she comments as follows:

The Ombudsman goes on to illustrate the theme of Chapter 2 by providing details of a number of complaints dealt with during 2007 which includes the following case.

The Ombudsman received a complaint against Beaumont Hospital (which is part of the Health Service Executive: Dublin North East Hospitals Group) from a woman who claimed that there was confusion surrounding the circumstances in which an un-prescribed dosage of medication was given to her mother over a five day period while she was in Beaumont Hospital.

In a comprehensive report the hospital explained that the main tool used to direct the administration of medicines in a hospital setting is the prescription chart. This chart contains details of the medication and formulation, who it should be given to, how much, which route, how often, and for how long. The chart is updated daily as medication is administered to the patient. However, for long stay patients, there are regular occasions when the details of the prescribed medication need to be re-written, manually, onto a new prescription chart. This is because, given that the chart is updated daily, the spaces where the nursing staff sign to indicate that medications are administered to patients become full.

The Ombudsman established that the complainant was first prescribed a drug, Mirtazapine, on 11 July 2006. This drug acts as an antidepressant and it has a sedative effect. The original dose was 15 mg. The frequency of administration of the drug was clearly stated as Nocté - at night. It was to be administered orally. A second prescription chart was commenced, on 24 July 2006, two weeks later. The earlier drug prescription details were re-written, by hand, on the new chart. However, the "frequency" of the dosage was not stipulated. In any event, the "frequency", as administered, was the same as the earlier chart, namely Nocté - at night. The prescription was recorded as having been administered at 22.00 each night for two weeks, until 3 August 2006. The second chart was full at that stage. A third chart was commenced on 4 August 2006. The earlier drug prescription details were again re-written on the new chart. Again, the frequency of administration was not noted. However, from 4 August 2006, the 15 mg dose was administered, three times per day, once at 8 am, once at 14.00 and again at 22.00. This was three times the original prescribed dose.

The Ombudsman identified two administrative errors in this process. The first was the failure of the doctor to specify a "frequency" on the prescription charts dated 24 July and 4 August 2006. The second administrative error occurred when a nurse, without apparently consulting with the doctor, recorded the "frequency times" of administration of the prescription as 3 doses per day, on the chart dated 4 August 2006. This entry was inconsistent with the original prescribed "frequency" of one dose per day. By the time the error was discovered the patient had been administered three times the intended dose of the medication over a period of four days and twice the intended dose for one day. The hospital's Medical Management policy stipulates that the nurse should ensure, among other issues, that the frequency and time of administration of medicine is stated.

The Ombudsman was satisfied that, when the error was identified on 8 August 2006, the hospital had taken appropriate action having immediately:

Furthermore, the hospital advised that, as a direct result of the patient's experience;

In this particular case, a medication error occurred when one of the patient's drugs was being administered to her. The Ombudsman's examination identified a possible systemic source of the problem, namely the flawed rewriting of prescription charts. This case highlighted an issue which needed to be examined in more detail with a view to eliminating, or at least minimising the possibility of a recurrence of a similar incident.

Accordingly, the Ombudsman pursued the matter further with the hospital. As a result, the hospital placed this issue on the agenda for its Integrated Quality and Safety Committee. The Ombudsman has asked the hospital to let her know the outcome of its deliberations in due course. The Ombudsman commended the hospital for the action taken and its acknowledgement of the importance of learning from medical errors which is an essential element in the improvement of patient safety in hospitals.

Individual cases reported on in Chapter Three include:

Department of Social and Family Affairs

An 89 year old man contacted the Ombudsman to complain that his application for a special reduced pre-1953 pension had been disallowed. In order to qualify for this pension, applicants who did not qualify for a standard contributory pension, were required to have at least 260 contributions paid either before 1953 or both before and after 1953. He indicated that he had been in insurable employment in the 1930s and 1940s and that he should have had sufficient contributions in order to qualify for the pension. The Ombudsman discovered that his application was disallowed as, according to the Department's records, there were only 109 reckonable insurance contributions paid on his behalf.

The Ombudsman noted that the man had provided the Department with details of his employment history relating to a specific period where no contributions had been recorded on his insurance record. However, it was apparent that no follow up action had been taken on foot of this information. Following the Ombudsman's intervention a detailed examination of the case was carried out by a Social Welfare Inspector. It was decided to award the man replacement contributions as it was established, beyond reasonable doubt, that he had been in insurable employment for the period stated. This gave him the appropriate amount of contributions required to qualify for the pension. His application was subsequently approved and he received a weekly pension of €114.70 plus appropriate arrears in excess of €25,000.

Health Service Executive

A 90 year old woman, whose only source of income was her Non-Contributory Old Age Pension, was refused a Nursing Home Subvention by the Health Service Executive (HSE), South. In assessing the woman's notional weekly income, the HSE applied a 5% notional income to the value of her principal private residence and a farm which she had transferred to her son within the previous five years. This, coupled with the complainant's Non-Contributory Old Age brought her over the income limit for Nursing Home Subvention purposes.

The Ombudsman accepted that the relevant Nursing Home Regulations provide that the HSE may impute an annual income based on the estimated market value of the principal residence of the applicant. However, given that this is a discretionary decision, the Ombudsman felt that the HSE had some latitude with regard to each individual's circumstances. The Regulations also provide that if an applicant has transferred the ownership of a farm in the five years prior to the application, the HSE may take into account any payment on transfer and/or any continuing income from the earnings of the farm. However, from her examination of the farm accounts, the Ombudsman discovered that the farm was showing a loss. The HSE had discretion to take into account any income, and by extension, any loss, from the farm holding.

The Ombudsman noted that, the complainant was on the HSE's waiting list for a public bed. However, when probed, the HSE was not able to say when she might be offered such a bed.

Accordingly, given that the HSE was not in a position to offer nursing home care to the woman, the Ombudsman asked it, in calculating the complainant's entitlement to Nursing Home Subvention, to take account of the fact that the farm was operating at a loss and also to consider its discretionary powers under the Regulations in relation to the applicant's private residence.

The HSE immediately reviewed the case and it agreed to pay a subvention of €190.80 per week towards the cost of the complainant's private nursing home care. In addition, the HSE paid her approximately €5,000 which covered the period from when she first applied for the Nursing Home Subvention. Finally, the HSE agreed to include the complainant on its waiting list for the payment of an enhanced subvention. The Ombudsman commended the HSE for its response.

Local Authorities

A seventy year old man complained that Sligo Borough Council had treated him unfairly in relation to his efforts to purchase his house under the 1997 Tenant Purchase Scheme (TPS). He claimed that having received an offer from the Council in 1998 to purchase his house, he subsequently accepted the offer but, later, the Council claimed it had no record of his agreement to purchase. The complainant was adamant that he signed a consent form and claimed the Council had lost it.

During her examination of the complaint the Ombudsman was able to establish the following:

Following the Ombudsman's intervention the Council carried out a thorough search of all housing records, during which correspondence relating to the complainant's tenant purchase application was located. The Council advised the complainant that he would be assisted in purchasing his house at the agreed 1998 price of €32,505. He subsequently contacted the Council and asked that the rent paid by him in the meantime be deducted from the sale price together with an allowance for works carried out to the house. The Council considered his request and agreed to reduce the price by €10,255 giving a new purchase price of €22,250. The complainant was very satisfied with the outcome.

Note for Editors:

The Ombudsman - a brief guide (attached)

The Ombudsman and the Disability Act 2005 (attached)

List of special reports (attached)

The Ombudsman - A Brief Guide

The Ombudsman investigates complaints from members of the public who feel they have been unfairly treated by certain public bodies. Her Office is impartial and completely independent of Government. If she finds a complaint justified she may recommend appropriate redress.

The Ombudsman has extensive powers in law. She can demand any information, document or file from a body complained of and can require any official to give information about a complaint. She can look into all administrative actions including:

Any individual, public representative, company, or organisation can make a complaint. Complaints can be made in writing, by telephone, fax or email, or by calling to the Ombudsman's Office.

Which Public Bodies are Subject to Investigation?

Government Departments and Offices

Local Authorities (County Councils, City Councils etc.)

Health Service Executive

An Post

When Should You Complain?

Before you contact the Ombudsman you must first try and solve your problem with the public body concerned. If you fail to resolve your problem and feel that the public body has not treated you fairly, contact the Ombudsman. When making a complaint try to give as much information as possible including any copies of letters and reference numbers.

What Will it Cost?

Nothing. There is no charge for dealing with complaints.

How Will the Ombudsman Deal With Your Complaint?

The Ombudsman's staff will screen the complaint to see if it falls within her remit and whether there is a basis to take it up with the public body. In the majority of cases complaints are resolved satisfactorily in a very informal way, for example, by discussing the problem with the public body or by examining the relevant files. In the more complex cases a formal investigation may be required.

If the Ombudsman finds that your complaint is wholly or partially justified, she will report this to the public body concerned. She may recommend that it should review its action, change its decision, or offer some form of appropriate redress.

Will the Recommendation of the Ombudsman be Accepted?

The Ombudsman has no power to force a body to accept or act upon her recommendation. If it does not, she may find it necessary to report on the matter to the Houses of the Oireachtas.

Are There Areas That the Ombudsman Cannot Investigate?

Yes, she cannot investigate: