A 21-year-old Co Limerick student with a history of depression hanged herself in a public psychiatric hospital unit around 16 hours after being transferred from a private hospital because her health insurance was inadequate, writes Martin Wall.
Ms Anne O'Rahilly died on September 20th, 2002, after being transferred from St Patrick's Private Hospital in Dublin to the public psychiatric unit at the Mid Western Regional Hospital in Limerick.
An expert group report on the case, seen by The Irish Times, highlights a litany of communications and systems failures on behalf of doctors, nurses and the health authorities in general leading up to Ms O'Rahilly's death.
The health board commissioned the review, which has been conducted over the past year by a consultant psychiatrist from Dublin, a former leading health service administrator from Cork, and a director of nursing from the midlands.
Ms O'Rahilly was admitted to St Patrick's on September 13th, 2002. On September 18th, her family were told there was insufficient health insurance. They were given until the following morning to decide if they could fund her care themselves.
Ms O'Rahilly was identified as posing a serious suicide risk but was nevertheless discharged at 9 p.m. on September 19th into her parents' care. They then brought her on the three-hour train journey to the public hospital in Limerick, where she arrived after midnight.
Staff found her hanging by a dressing gown belt from a shower curtain support at 1.30 p.m. on September 20th.
The report has found that letters given to the family by St Patrick's to bring to Limerick did not clearly identify that Ms O'Rahilly had been treated in a special care unit.
The letters were incomplete because the family were given photocopies of larger originals. During the copying a crucial detail - the reference to a special care unit - was left out. "Documentation relating to the prescription of medication, which had a ward designation, were misaligned and in the case of some, foolscap-sized material had been photocopied onto A4-size pages with the loss of some information."
The report found the doctor on call in the Limerick unit on September 20th had had "limited" training and supervision in adult psychiatry. In addition, the report found the nurse who conducted the initial nursing assessment in Limerick had not read the detailed information provided by St Patrick's.
The review group also determined that on his ward round the following morning, the treating consultant at the Limerick unit failed to notice a handwritten letter addressed to him from the referring psychiatrist at St Patrick's.