‘Lessons have to be learned’
HSE issue apology after woman in hospital care drowns
The HSE has apologised to the family of a woman who died while in the care of the Acute Psychiatric Unit at Cavan General Hospital as a voluntary inpatient.
The woman died despite grave concerns communicated by her family at a meeting with medical chiefs less than 24 hours earlier.
She had been in the care of staff at the unit for close to four months when she went missing.
An inquest heard details of a litany of errors, which occurred in the lead up to the woman’s death. These included the woman being allowed to leave in the company of another “vulnerable” inpatient - against her care plan and contrary to the expressed wishes of her family; failures to adhere to policy; and a neglect to update the woman’s treatment plan.
Her death acted as a “catalyst” for a review from which 11 specific recommendations were made.
Held at Cavan Courthouse last week (March 15), a day after the fourth anniversary of the woman’s death, the inquest heard an emotional account of what a “loved wife, mother, daughter, sister and friend” she had been.
“She was kind, generous beyond words, a homemaker, and a perfectionist in every sense of the word. Words don’t go far enough to describe the person she was and the many legacies she left behind. She has left a void in the lives of her family that can never be filled.”
It was stated the woman, aged in her 50s, had suffered from “episodes of depression”, but her condition was “managed” with medication.
Her illness, it was stated, “did not define her” and “she led a full life full of laughter, fun and happiness”.
The inquest was heard before Coroner Dr Mary Flanagan and a jury of seven.
The woman’s sister, in her deposition, stated that “lessons must be learned” to ensure no other family “endures the suffering and heartache that we as a family have to endure every day of our lives”.
‘Fog of depression’
Voice breaking momentarily, the woman’s sister steadied herself before continuing.
She said her sister had filled her days visiting their elderly father with fresh baked goods, holidays, nights out where she’d “manage” to get her husband out to jive, football matches, weekend drives and meeting up with family and friends. There was also “the shopping”, her weekly trip to the hairdresser, all the while the woman had an ability to be there “to help others, give good advice, and always have a listening ear”.
The “terrible fog” caused by depression “cut her off from all of this”, and it was from this “she needed to be protected”.
The Coroner’s Court heard that the woman’s “first episode” of depression happened around 1989/90 and over the years the “odd short episode” would be treated in the community by increasing her medication and decreasing it “as soon as her mood lifted again”.
In early 2018 the woman “suffered a relapse”. It was different to any time before. This time she was having “suicidal thoughts”. In response she “plucked up every ounce of courage she had” and was admitted to Cavan General Hospital’s Acute Psychiatric Unit on a voluntary basis.
She was admitted again in December 30, following an attempt on her life. Both the woman and her family considered the secure psychiatric unit a “safe space” for her.
“She told us she wanted to go back to hospital, that she felt safe there. She told us that effectively being in a hospital guaranteed her safety.”
The woman’s sister said, as a family, they had “on several occasions” expressed concern about her “deteriorating condition” and fear of the “real and immediate risk to her life”.
In her sister’s presence the woman had on “numerous occasions” advised her care team she “could not trust herself” and did not want to go home until such time as she felt “well” again.
“She believed that medication would work as it always did before,” said the woman’s sister.
On January 21, 2019, the woman returned from an “unaccompanied” walk to Cavan Town. Following this “grave concerns” were expressed by her family at allowing the woman go for walks “unaccompanied” again.
By now she felt the medical professionals were “not taking her seriously”.
Arising from this the woman’s family attended a meeting at 10:30am on March 13, 2019, with Dr Rachael Cullivan, Consultant Psychiatrist, Cavan/Monaghan Hospital Group, the woman’s psychologist, her key worker nurse Pauline McCrudden, and Dr Vigo Joel.
Her family say a “second opinion” was never sought, nor had she herself ever refused one. “She would have gone to the ends of the earth to get help,” contended the woman’s sister.
Before the meeting, when they had spoke with her, the woman told her family she “did not want to get up in the morning and just wanted to get her life ‘over with’”.
Again her family “emphasised” their foremost concern was the woman’s continued “safety”.
The following day, March 14, the woman’s sister’s phone rang. The time was approaching 9am and the woman sounded “very agitated”. She “wanted to get home”.
The family had been reassured the previous day that the woman would “not be let out of the unit” other than with a staff member or with a member of her family. “We were reassured by this. It felt like it was the first time we had been listened to.”
Around 11:45am the woman’s sister got another call. She could not answer immediately, but when she tried to reply, her sister “did not answer”.
“I then checked and saw she had left a message. I listened to the message and my world fell apart.”
From the recording, mis-dialled while in her pocket, the woman was talking to an employee of Bus Éireann in Cavan Town.
She immediately contacted the woman’s husband who in turn called the hospital to check on his wife.
Alleged terse phone exchanges, claimed by the family, were denied by hospital staff to the inquest.
The woman’s family was represented at the hearing by Senior Counsel at Callan Tansey Solicitors, Roger Murray; while Caoimhe Daly BL, instructed by Mason, Hayes and Curran, acted for the HSE.
Solicitor Suzanne Delahunt appeared on behalf of the State Claims Agency.
The hearing was told a frantic search for the woman ensued. Her sister travelled up the N3 stopping buses as she came by them. Back in Cavan, gardaí were also informed, and a request made by Superintendent James Coen to access the “ping” location on the woman’s phone.
It transpired that, instead of a bus, the woman got a taxi. The driver’s account detailed that the woman had been “quiet” on the journey. She told him she had been visiting a sick relative at the hospital.
He responded by saying: “All we can do is pray for them. That’s all you can do”.
She replied: “That’s all you can do.”
Several gardaí also gave witness statements.
The Coroner’s Court heard that the woman’s body was recovered hours later and she was pronounced dead at 16:46. Her husband identified the body.
The family said it has been “deeply distressing” for them that the trust they placed in the woman’s care team and Acute Psychiatric Unit had gone awry.
CCTV footage from the hospital for March 14, 2019, showed the woman leaving through the front door with another patient at 10:54am. The other patient, referred to as ‘Patient B’, had asked a “student nurse” for permission. On a white board in the office both their names were written down, with a return time of 11:30am.
At 11:24am the woman is seen returning to the front of the hospital with ‘Patient B’. They talk, her sister said, about the woman “going home”.
They enter the hospital through the front door, still talking, and less than 10 minutes later the woman is observed running for a bus pulled up outside. The woman told ‘Patient B’ she had seen a family member. This was then relayed to unit staff.
A nurse in the unit, though she does not recall having done so, erased the return time, and noted ‘care of sister’ beside the woman’s name.
The woman was described as a “vulnerable patient” by her sister. “She was unable to look after herself. She was in an acute locked unit.”
Instead, the inquest heard, the woman was allowed leave in the presence of another “vulnerable patient”.
It was stated the woman was “not assessed” by care staff in the wake of the family meeting on March 13.
“Had we for one second thought she would have been left alone at that psychiatric unit with another vulnerable patient, we would have been in there,” said her sister.
There had been an incident in January when the woman wanted to go to the hospital’s chapel by herself, but was urged by unit staff not to go unaccompanied.
“She always listened?” asked Mr Murray. “Absolutely,” said the woman’s sister in reply. “She would have done anything to get well.”
Mr Murray outlined how the policy with regards to patient leave and missing persons was drafted in 2016. Only two days before the hearing, an updated 2023 copy, with amendments was furnished to the woman’s family’s legal team.
Elsewhere he pointed out that the woman’s individual care plan, dated March 12, 2019, was not signed by her, nor was the box signifying it had been presented to her ‘ticked’. The plan was due to be updated a week later.
The court heard that the ‘Nurse in Charge’ on the ward on March 14, the day the woman went missing, failed to check this. The woman had been ‘Level 3’ observation at the time, having been considered ‘Level 2’ before that. She had slept poorly the night before due to disturbances on the ward. This also was not regarded.
Further concern with regard to changes in the woman’s medications and dosage, and the potential side effects of same, were accepted as “reasonable” by Dr Cullivan when pressed by Mr Murray.
Dr Cullivan said the woman had appeared “impatient and frustrated” that the medications had not taken the desired effect. She added she was “very well aware” of the concerns highlighted by the woman’s family.
Pathologist Dr Munah Sabah, addressing the hearing via video-link, ascribed the cause of death to the inquest as by ‘drowning’ following a post-mortem at Our Lady of Lourdes Hospital in Navan on March 15, 2019.
A ‘Narrative’ verdict was sought by Mr Murray and recommended subsequently to the jury by Dr Flanagan.
Dr Flanagan concluded by extending her sympathy to the family of the woman. She said her death had been “terribly tragic”.
Dr Fergal Leonard, Consultant Psychiatrist and Acting Executive Clinical Director of Cavan Monaghan Mental Health Service, said he was “deeply sorry for what happened” to the woman.
“I am deeply sorry that she died whilst she was under our care at the Acute Psychiatric Unit in Cavan. I am very sorry for the failures in the care provided to her by our service. I want to sincerely say to you that her death is deeply regrettable to me, all my colleagues, and all the staff of the service.”
Mr Leonard said the woman’s death was a ‘Category 1’ event under the HSE’s Incident Management Framework. A preliminary assessment was carried out in its wake, following which a Systems Analysis Investigation took place.
This was completed by an external reports body, internal to the HSE, which came up with a total of 11 recommendations.
Mr Leonard was asked to respond to what changes had occurred in respect of the specific concerns highlighted by family and by the inquest jury in its own set of recommendations.
Though new policies have since been introduced, including stricter rules on patient leave, the whiteboard system, which the jury described as “confusing”, still exists.
“The problem is that those type of policies frequently don’t arise until a situation like this arises,” remarked Dr Flanagan.
Dr Leonard said the ‘AWOL’ (Absent Without Leave) form used by the hospital after a patient goes missing “hasn’t changed significantly” since either. This will be reviewed to allow more information to be noted/recorded.
He went on to say there was now a “100 per cent compliance with staff” in reference to policies regarding individual care plans. They had introduced a “bespoke” training module three years ago, and he said with training the “standard of care planning will improve”.
Regarding the “safety of patients”, Dr Leonard said “training” is ongoing, including intensive STORM (Skills Training on Risk Management) self-harm prevention training.
What had happened to the woman while in the hospital’s care had been a “catalyst certainly for some” of the changes, he admitted, before accepting a recommendation from Mr Murray that the location of the patient getting leave, together with the contact details they’re on leave with, are included in future.
In a statement, the HSE said: “The HSE Cavan/Monaghan Mental Health Service has apologised to the bereaved family and extend their deepest condolences to them.”
The spokesperson added: “The HSE can confirm that a Systems Analysis Review was completed subsequent to this death and that all recommendations from this review have been implemented.”
* The Anglo-Celt has taken an editorial decision not to publish the name of the woman and her family, with reference to a number of reporting guidelines on sensitive issues.
MENTAL HEALTH SUPPORTS AND SERVICES AVAILABLE
If you or a loved one are affected by the contents of this article (left) or feel you may need support, please contact any of the following Mental Health Services.
A non profit organisation that provides free counselling services.
Phone (049) 432 6339
Visit 26 Bridge Street , Cavan, Ireland
Samaritans services are available 24 hours a day, for confidential, non-judgmental support.
Freephone 116 123
Visit www.samaritans.ie for more information.
Pieta provide a range of suicide and self-harm prevention services.
Freephone 1800 247 247 anytime day or night
Text HELP to 51444 (standard message rates apply)
Visit www.pieta.ie for more information
A free 24/7 text service, providing everything from a calming chat to immediate support for people going through a mental health or emotional crisis.
Text HELLO to 50808, anytime day or night
Visit www.text50808.ie for more information.