The Malta Independent 2 December 2023, Saturday
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Updated: Man's disappearance from SVPR down to ‘lack in standard of care’, inquiry finds

Sabrina Zammit Monday, 1 August 2022, 12:40 Last update: about 2 years ago

The disappearance of Karmenu Fino from St Vincent de Paul was the result of shortcomings in the standard of care provided by employees rather than a systematic failure, according to the conclusions of an internal inquiry into the case.

The conclusions were announced by Active Ageing Minister Jo Etienne Abela in a press briefing on Monday.

The internal inquiry, conducted by retired judge Geoffrey Valencia, was triggered on 29 June, just a day after St Vincent de Paul patient 83-year-old Karmenu Fino went missing.


It was later revealed that Fino suffered from dementia, and had simply walked out of the facility in the early hours of the morning.  He is yet to be found.

During the brief, Abela explained how, from the summary which he had received just this morning, written by the Valencia himself, “it shows that several employees on that night [the night that Fino went missing] failed in their duty of standard of care. They did not respect the operating procedure of the facility which resulted in the unfortunate disappearance of Fino.”

The results of the inquiry have been forwarded to the management of the facility, who although they are not able to take disciplinary actions against the eight employees in question, can still take preventative measures.

The inquiry, which took a total of five sittings to conclude, will also be forwarded to the Commissioner for the elderly Godfrey Laferla, to the Social care and Standards Authority’s CEO Lisa Cassar Shaw.

The Ministry has, thus far, held meetings with Fino’s family and the union who represents the employees in question.

Referring to the body of a man which was found in the middle of July at an advanced stage of decomposition in a field near Ghar Dalam, in Birzebbuga, Abela said that they are not excluding the possibility of it being Fino’s.

However, this cannot be confirmed as police are still waiting for DNA test results.

Speaking about the inquiry, the minister explained how the results are not to be taken as a reflection of the many employees who do their job to the best of their abilities “allowing millions of elderly patients to receive the best care.”

“This inquiry should not discourage others [employees], as in my opinion these results are the exception not the norm,” he said. 

He added that the ministry chose retired judge Geoffrey Valencia to lead the inquiry as it wanted its results to be as independent as possible.

Early last June the same retired judge was appointed as a member of the Independent Police Complaints Board, replacing Michael Cassar, a former police commissioner.


Details from the night of Fino’s disappearance

Speaking about the case itself, the minister said that in accordance with current procedures the gate closes at 11pm and opened again the following morning at 7am.

However, during the night of Fino’s disappearance, the gate was left open.

“In the CCTV footage the gate was left opened, for reasons unknown,” he said.

To confirm that this was not something which happened frequently, camera recordings were also checked from previous days, and it showed that it was always closed and opened on time.

Apart from that the standard operating procedure also requires that whoever oversees the ward for the night does three rounds, one at 11pm, 1am and the last one at 3am. Additionally, “whoever is in night shift needs to give a hand over.”

Abela said that in this case such handover was not done correctly or was not done altogether.

A total of four carers/nurses together with four security guards are in charge of 36 patients per ward, as per standard, Abela explained.

On the night of Fino’s disappearance, there were a total of 34 patients, yet there were still four carers/ nurses together with four security guards “this shows that they weren’t understaffed.”

Lastly Abela said that from the eight people who were required to give their statements, one of them withdrew his statement whilst others decided not to chip in.

One of them said that Karmenu Fino was handed tea at around 6am, which Abela said cannot be true since CCTV shows otherwise.

He said that this shows a level of inconsistency between the statements given and camera’s recordings.


New measures at St Vincent de Paul

Abela went on to explain how new security measures have been put in place since the disappearance of 83-year-old Karmenu Fino.

“As a matter of urgency, we have increased security monitoring at the facility, this after having reached an agreement with companies which offer security personnel,” he said.

Apart from that, he added, the CCTV system currently in place is also being revisited.

Abela said that the Ministry is looking into other security measures such as tags for patients, which he said is a system which is already being used in other elderly care homes.

He said that such tags would need to be within the parameters of the law, whilst still maintaining the dignity of the person together with some medical information.

St Vincent de Paul Employees have also been told that incident reports need to be filled properly and immediately, so that the level of miscommunication is minimised.

The duties of the nurses and carers have also been tackled in the recommendations of the inquiry, which in Abela’s words will allow for “better vetting of future employees.”

Another recommendation speaks about the need for more harmony between workers and management.

Asked during the briefing, Abela said that some might be allowed to just roam around the facility with their families, whilst others will be allowed to leave the premises to have lunches with their families.

He added that a team of professionals is currently taking care of finding the right test to assess patients’ cognitive abilities.

Although he could not give a definitive date for when such process will finish, he said that these tests have already started to be conducted on patients.


Filling patients with security guards 'not the solution' - PN

In a statement, the Nationalist Party said now that the government has the inquiry report in hand it should take all necessary actions to ensure that residents of SVPR are truly treated with respect and dignity.

Elderly people at the home should not be treated like “prisoners” and the shortcomings found cannot be solved simply by filling the wards with security guards and structures that close all accessibility, it said.

These people have a right to movement and those who are not in a condition to take decisions on their won have a right to assistance.

The PN also said that the government had reacted by placing all blame on the employees.

All those who have failed their duties, including the government itself, should carry responsibility, the PN said. It added that the government has been ignoring the pleas made by the MUMN for months to increase employees as the care home.

The government must invest more in employees and their training if it truly wants to give the elderly a better quality of life.

The statement was signed by MPs Paula Mifsud Bonnici, David Agius and Ivan Castillo.


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