The Gibraltar Mental Welfare Society says it would like to comment on a case referred to in the recently published Ombudsman's report for 2024. The report highlights the case of a 71 year old patient who spent the last months of their life between St Bernard's Hospital and Ocean Views. 

A statement continued: “Unfortunately, the report offers a complete indictment of the treatment offered by the GHA to this individual, with complex physical and mental health problems. Other than the impeccable treatment provided by ICU during this period, the rest of the time the treatment in both hospitals was woefully inadequate. 

“The patient's diabetes was completely mismanaged. The patient suffered between 183 and 213 hypoglycaemic episodes in an equal number of nights. This is a shocking fact, primarily as a risk to life, but also as a factor which exacerbated the Patient´s mental health issues.

“On the Patient's last night they had been experiencing difficulty breathing since 3:45 am and it is documented that a doctor was contacted at 5:50 a.m. to certify the Patient´s death. The family was contacted by the GHA at approximately 6.00 a.m., so by the time they arrived at the hospital, the Patient was already deceased. The fact that the Patient died without any family around them weighs heavily on the family and is at the centre of their complaint.

“Other than the major failing in terms of the mismanagement of the Patient's diabetes, the report finds that according to Expert 2 “the Patients’ mental health needs were not adequately addressed throughout their stay at St Bernard’s Hospital, lacking recognition, assessment, and care planning.”

“There was also a lack of a structured discharge plan in relation to the patient's sudden move- overnight- to residential services, with no involvement of Patient or family in this decision, a move which had a very detrimental effect on the Patient.

“The report  also records the fact that the Patient was mostly given the wrong diet for their medical needs in St Bernard´s, including non-diabetic desserts. On one occasion, a member of the family resorted to writing “Diabetic” on the white board above the Patient´s bed, in an attempt to stop the same mistakes from happening, even though they reported this matter to staff on over 30 occasions.

“On another occasion, the Patient´s walking stick was confiscated during an episode of crisis and a Zimmer frame not provided. The Patient went to the bathroom without supervision, slipped and fractured a knee. Expert 2 concluded that the GHA did not appropriately review the Patient’s falls risk and mobility needs.

“The Ombudsman's report on this case reflects abysmally on the GHA, with the Patient being treated in a totally unsatisfactory manner. It is exactly the opposite of what the GMWS considers should be in place for a service user. The individual needs to be treated in a holistic manner which takes into account their complex needs, and which ensures the correct treatment of both physical and mental pathologies. This Patient was not treated either with the necessary respect and compassion which should be afforded to any patient, and neither did they receive appropriate medical treatment for their condition.

“The Society welcomes the Ombudsman´s recommendations, has reservations as to whether they will in fact be implemented but hopes that they will. The Society trusts that when the Single Point of Access in the new Hub is constructed, and “The new model of care” is fully implemented, that this kind of disgraceful treatment of a patient never happens again.”