By: Michael O’Farrell

Investigations Editor

FIVE St John of God executives who shared millions of euros in secret payments from the charity were involved in the case of a child who died in respite care.

Six-year-old Tristan Neiland died on January 5, 2013, just feet away from medical equipment that would have saved his life. He was in the care of Angels Quest, a respite home run by the St John of God charity in south Dublin. This week Tristan’s mother Angela Neiland and her husband Andrew received an apology from St John of God Community Services after their case against the charity was settled.

Back in November 2013, clandestine payments totalling some €1.8m were paid out to 14 SJOG executives in the same month that three out of six internal reports into the incident were completed.

Mrs Neiland told the Irish Mail on Sunday this week she was shocked when she read of the secret top-ups to SJOG executives – first revealed by the MoS – especially as she was acutely aware of the impact cutbacks were having. ‘I felt really sick reading that,’ she said. ‘That was disturbing.’ One of the five executives involved in Tristan’s tragic case is Phil Gray who was the director of Carmona Services, which runs Angels Quest, at the time of Tristan’s death. She received €31,000 in top-up payouts.

Mrs Gray, who later became regional director for SJOG, dealt directly with the aftermath of the tragedy and was involved in setting in train a series of internal reports.

The main report into the incident is dated November 15, 2013 – 10 days after the charity was asked by the HSE to confirm that all salaries were in compliance with public pay policy and just four days before the charity lied to the HSE to say they were in compliance. Another key internal report is dated November 27, 2013 – the day before the top-up payments were approved by the governing body of SJOG.

One of the reports, seen by the MoS, concluded that some of the failures in Tristan’s care amounted to abuse and neglect – as defined by the HSE’s safeguarding policies.

Other internal reports concluded that handwritten notes and a risk assessment was likely fabricated – and that signatures appeared to have been forged after Tristan’s death. One failure is the fact that Tristan was left unattended for at least an hour when the SJOG service had been told that he required either a full-time care or a SATS monitor to alert staff in the event of a seizure.

Instead Tristan’s monitor was not attached, and the only system in place to alert staff of a problem was an ineffectual baby monitor in the corridor outside. Tristan was also left unattended for at least an hour – even though staff said they had checked him every 15 minutes. Tristan died during this hour alone, something that causes untold grief to his mother who had only recently agreed to placing him in respite care having personally monitored her son since birth by sleeping beside him every night.

The ‘misrepresentation of vital information had a distressing effect on Tristan’s parents and to an extent frustrated the work of the investigation,’ one report reads.

But the most distressing part of the tragedy – as described by Tristan’s mother Angela in today’s MoS – is the way in which her detailed instructions about the care of her son appear to have been misrepresented. This, Mrs Neiland believes, was a bid to deflect blame for Tristan’s death by incorrectly placing responsibility on her.

Mrs Neiland told investigators that this apparent misrepresentation began with a conversation with an employee over the open coffin of her son during his wake. According to Mrs Neiland, a staff member told her that a monitor that would have alerted staff to Tristan’s distress had not been used. The staff member contended that Mrs Neiland had agreed the monitor need not be used if Tristan was checked every 15 minutes – a contention Mrs Neiland says is completely false.

The investigators were presented with a risk assessment document – which the Neilands saw for the first time after the investigation began.

A report expressed ‘concerns regarding the veracity of this document which it has concluded is spurious, and contained a signature of a care assistant which was not in fact the care assistant’s signature, and was most likely designed to give the misleading impression that a risk assessment had been undertaken’.

When investigators examined the document, they found: ‘The weight of evidence suggests that this document was written after the night of the 5th Jan 2013.’ They went on to say the document is ‘invalid, spurious, misleading and false’.

There is no suggestion that Phil Gray – or any other senior SJOG executive who shared in the secret payouts – was directly involved in any care failures or misrepresentation related to Tristan’s death. But confidential reports point to apparent deficits in governance standards at SJOG as a ‘key contributory factor’ in Tristan’s death. These overall governance failures included an apparent lack of risk management systems and no formal system for reporting or analysing near misses.

Because of this Tristan’s death was not even registered as an adverse event – something that would have required it to be reported to Hiqa. Investigators even found that brochures and the website for the SJOG respite home referred to a ‘Respite and Referrals Committee’. No such committee existed.

This week’s apology was signed by Clare Dempsey the current CEO of St John of God Community Services, which is funded by €125m of taxpayers’ money each year.

Ms Dempsey received nearly €60,000 in the secret payouts. But several other SJOG executives who shared millions in payments have been closely involved with the case as it was brought to court.

For instance, Mrs Neiland dealt with Bernadette Shevlin – who received almost €56,000 – and Sharon Balmaine, who received almost €146,000. Both served at executive level at St John of God Community Services Ltd.

Mrs Neiland also encountered SJOG group CEO John Pepper – at one point calling him in anguish when he was in New York.

Eventually Mr Pepper – who is the person with overall responsibility for all SJOG operations – apologised in person to Mrs Neiland together with Br Donatus Forkan, the Provincial of the St John of God order. Mr Pepper benefited to the tune of €2m in all from the payments.

A spokesman for SJOG Community Services reiterated its apology. He also said SJOG had been working to address recommendations made in the wake of Tristan’s death. He said the organisation was ‘fully engaged’ with the HSE in response to a review into payments to managers.

 

Respite staff falsified time ambulance was called

Staff at angels Quest respite centre ‘misrepresented’ how often they checked on Tristan on the night he died, falsified the time an ambulance was called and falsified a risk assessment document after his death.

Care centres create risk assessments before taking in a child with Tristan’s complex needs. When investigators examined Tristan’s assessment they found: ‘the weight of evidence suggests that this document was written after the night of the 5th Jan 2013.’ they went on to say the document is ‘invalid, spurious, misleading and false’.

The report states the document ‘contained a signature of a care assistant which was not in fact the care assistant’s signature, and was most likely designed to give the misleading impression that a risk assessment had been undertaken and managed’.

When asked how often Tristan was monitored, staff initially said checks were done every 10 to 15 minutes – even though Tristan’s mother said checks needed to be done at shorter intervals. But when investigators studied all the statements it became clear Tristan was not checked during the 56 minutes before he was found collapsed. They found staff ‘misrepresented the frequency of the checks on Tristan that night’.

One employee recorded Tristan was found at 22.30 and the ambulance was called immediately. But records from the emergency services show this call was made at 22.58 and Tristan was found at 22.56. Investigators concluded this falsification was done in collaboration with other staff to support the claim he was regularly checked.