GMWS raises concerns over GHA care following Ombudsman’s 2024 report

The Gibraltar Mental Welfare Society has raised concerns about the care provided to a 71-year-old patient by the Gibraltar Health Authority in a case detailed in the Ombudsman’s annual report for 2024.

The case detailed in the report concerns a patient who spent the final months of their life between St Bernard’s Hospital and Ocean Views, receiving what the GMWS described as “woefully inadequate” treatment for both physical and mental health issues.

According to the GMWS, the only aspect of GHA care described as “impeccable” was that provided by the Intensive Care Unit.

The remainder of the patient’s experience represented a “complete indictment” of the treatment offered, the Society said in a statement.

The patient, who had diabetes and complex mental health needs, reportedly suffered between 183 and 213 hypoglycaemic episodes over an equal number of nights.

The GMWS described this as a “shocking fact” that not only posed a risk to life but also worsened the patient’s mental health.

The patient experienced breathing difficulties from 3.45am on their final night. A doctor was contacted at 5.50am to certify their death, and the family was contacted at approximately 6.00am.

The Society noted that the patient died without any family present, which weighs heavily on relatives who was this was at the centre of their complaint.

The report also highlighted other failings in care.

According to one expert cited, the patient’s mental health needs “were not adequately addressed throughout their stay at St Bernard’s Hospital, lacking recognition, assessment, and care planning.”

In addition, the patient was transferred overnight to residential services without a structured discharge plan or family involvement, a move that had a very detrimental impact.

Dietary needs were also mismanaged.

The report found that the patient was frequently given food unsuitable for a diabetic diet.

In response, a family member wrote “Diabetic” on the whiteboard above the patient’s bed after raising the issue with staff on more than 30 occasions.

The report further noted that during a mental health crisis, the patient’s walking stick was confiscated and a Zimmer frame was not provided.

The patient subsequently slipped in the bathroom and fractured a knee.

Expert findings concluded that the GHA had not appropriately assessed the patient’s falls risk and mobility needs.

The GMWS said the case reflected “abysmally” on the GHA and described the treatment as “totally unsatisfactory.”

“The Ombudsman's report on this case reflects abysmally on the GHA, with the patient being treated in a totally unsatisfactory manner,” the Society said.

“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.”