AN INVESTIGATION by the Ombudsman has found Limerick Regional Hospital failed to advise the coroner in a timely fashion about the death of a 61-year-old patient 52 hours after falling out of bed.
The coroner was notified by the hospital two weeks after the man died and only after the man’s family had gone to An Garda Síochána to express concern. By then it was too late for a post-mortem examination.
In a report published yesterday, Ombudsman Emily O’Reilly, who investigated a complaint from the dead man’s family, said there had been a number of “unacceptable failings” at the hospital both before and after the man died in November 2005.
She said these should be acknowledged, apologised for, and steps taken to prevent them happening again.
The man was admitted to the hospital after a stroke but was still able to sit in his chair and chat to his family the day before his fall. But within hours of the incident, his family was advised to come to the hospital.
He suffered a broken tooth, an 8cm laceration to the back of his head and cuts to his tongue, and subsequently entered an unconscious state and died.
The Ombudsman said it was reasonable for the family to have doubts about the HSE’s contention that his death was caused purely by his stroke and not contributed to by the bad fall he suffered.
In complaining to her office, the family said they wanted a post- mortem even at that late stage when it would involve an exhumation.
However, Ms O’Reilly said she had no powers to do this. A coroner, she said, can request the Minister for Justice to order an exhumation in certain circumstances. But following an inquest into the man’s death in April 2006, the coroner, who returned an open verdict, did not make such a request.
Ms O’Reilly found the failure to notify the coroner was largely because the team who admitted the patient and cared for him after his fall was off duty when he died on a weekend.
There was “a lack of joined-up thinking between all staff [medical, nursing and risk management] that could have ensured that adequate consideration was given to the fall’s contribution” to his death.
An on-call junior doctor was called to certify the patient dead.
Ms O’Reilly said she was aware the coroner had asked for better education and training of junior doctors about procedures relating to post-mortems, but she was not convinced appropriate measures had been taken to prevent the same error occurring again.
Several other issues were also highlighted in the Ombudsman’s report.
There was no record of the patient’s death on the hospital’s computer system almost two weeks after he died when the family looked for the medical certificate showing cause of death. His daughter had to retrieve his medical file from the ward where he died and bring it to the hospital’s records department to ensure records were updated.
There were unsigned changes to the original entry in the mortuary register which initially suggested a post-mortem was required, there was an absence of a falls risk assessment on the patient, and four different times for his fall were recorded by staff.
In addition, when he died he was on a large ward and a curtain was pulled around his bed. While his family were grieving around him, a catering staff member inquired if he would be having breakfast.
Eventually, the family were asked to leave so he could be taken to the mortuary but they were later told by the undertakers his body remained in his bed on the ward for a further six hours. If the family knew he was lying alone in a busy ward, they would have arranged for someone to sit with him.
The HSE has accepted the findings of the report and apologised. It said the delay in notifying the coroner was not intentional, and the subsequent adverse effect on the family was deeply regretted.