Patrick Joseph Walsh should not have bled to death in Monaghan General Hospital. But why did he not get the medical attention he needed to save his life, asks Eithne Donnellan, Health Correspondent
If Patrick Joseph Walsh had survived long enough to need more blood last Friday week, there would have been yet another problem facing doctors at Monaghan General Hospital. Having given the 75-year-old seven pints of blood it had no more units of his blood type in stock in the hospital blood bank.
In the event no more was needed. The semi-retired farmer from Killanny, Carrickmacross, died at about 7.25am. He had bled to death.
Politicians, doctors, a local hospital action group and his distraught family are agreed on one thing - that he should not have died. So what went wrong and why?
Patrick Joseph (or Pat Joe, as his family and friends knew him) had little contact with doctors or hospitals until he fell and broke his hip on Tuesday, September 20th last. He was taken by ambulance to Our Lady of Lourdes Hospital in Drogheda late that night. His hip required surgery and he was operated on on Friday, September 23rd.
In the days that followed, like patients after any operation, he was on a drip and lost some weight. It was discovered he also had a bleeding ulcer.
According to his nephew Edward Walsh "a temporary job" was done on the ulcer in Drogheda. It is understood the ulcer was injected, a recognised way to try and stop it bleeding.
Some days later, and with Pat Joe Walsh looking like he was recovering, it was decided he should be transferred to Monaghan Hospital for physiotherapy. He was transferred a week last Thursday, October 13th, arriving by ambulance in Monaghan around 5.45pm.
His family, it appears, got a call when he was on his way to Monaghan to inform them he was being transferred - they knew he would be transferred but weren't sure when - and on his arrival in Monaghan staff there rang Edward Walsh to ask him what he considered to be some basic questions about his uncle. He asked why they didn't already have this information from his records in Drogheda. They said they had his medical records but they "knew nothing about him".
Edward was concerned. He finished some farm work and he and his sister Deirdre went to the hospital, arriving there around 8.20pm. They found Pat Joe in a bed without a pillow and the leg which had been operated on was "hanging off the side of the bed". They propped him up and gave him a drink of water. When they left him at around 9.30pm he seemed in good form.
Edward was in bed when, shortly after midnight, he got a call from the hospital to say his uncle had "taken a turn for the worse and was critical". The caller told him to ring the hospital back for an update in half an hour. When he did he was told Pat Joe had "regressed" and "they had sent for the priest".
Edward and his family rushed to the hospital. They got there at about 1.20am. It seems Pat Joe had collapsed earlier, had been resuscitated and was by then in intensive care.
Realising that Pat Joe's ulcer was bleeding and believing he would need emergency surgery a registrar (junior doctor) at the hospital had earlier begun calling other hospitals in the north-east region and beyond to see if he could transfer the patient, as Monaghan Hospital is not allowed to carry out emergency surgery.
The registrar tried Cavan General Hospital, Our Lady of Lourdes in Drogheda and Beaumont Hospital in Dublin and it's claimed he was told none could take the patient as none had a free intensive-care bed.
It emerged in the days since Pat Joe's death that all three hospitals had vacant intensive-care beds. It is not known why then they were not given to the Monaghan patient. Beaumont likes to hold onto one intensive-care bed for its own in-patients in case any of them become very ill, but it claims it told the registrar when he phoned in the early hours of the morning to come back to it again if he had no luck elsewhere.
After failing to source a bed in any of these three hospitals the registrar rang the consultant on call that night at Monaghan General. The call is said to have been made at about 1.40am. The consultant on call arrived at the hospital shortly after that.
Looking back, Edward Walsh says "every hospital in Ireland should have been tried" to see if they had a bed for his uncle. Why staff in Monaghan did not try other hospitals, even those across the Border in Enniskillen or Omagh, is not known. But it may have been that the patient had become so unstable he was incapable of being transferred as time went on.
Neither is it known why the three hospitals contacted indicated they couldn't accept the patient when we now know they probably could have.
THE DEATH OF Pat Joe Walsh is now the subject of an independent investigation ordered by the Minister for Health, Mary Harney. It will be carried out by Belfast-based surgeon Declan Carey who, incidentally had been expected to take up a post in Drogheda recently, but didn't in the end.
Many, not least Harney, the Taoiseach Bertie Ahern and the head of the Health Service Executive Prof Brendan Drumm, have suggested that protocols, including the ban on emergency surgery in Monaghan, should not prevent every effort being made to try to save a man's life. However, doctors in Monaghan say it's not as simple as it sounds and an attempt is being made to scapegoat them.
The reality is, they say, that theatre nurses in Monaghan Hospital go home at 5pm and the theatres are then locked. So why didn't somebody in the hospital find the key and open one of them up last Friday morning?
One doctor in Monaghan says even if staff broke down the theatre doors with a sledge hammer early last Friday week it would have been impossible to operate on this patient without theatre nurses on hand. There are no theatre nurses in the hospital after 5pm. Neither are these nurses on call out of hours.
Doctors in the hospital also stress that if they did dispense with protocol, managers would be down on them like a tonne of bricks. They would also be uninsured to carry out work which they are barred from doing.
"We are put in an impossible situation . . . it is a terrible dilemma," one doctor in the hospital says. Had the hospital still been on call for emergency surgery, doctors in Monaghan Hospital believe they could have operated on Pat Joe Walsh and possibly saved his life.
"But our hands are tied. We are not left to deal with people ourselves. We have protocols by the bucket," one says. It is claimed that a surgeon at the hospital who conducted an emergency operation earlier this year, in contravention of protocol, was reprimanded.
Unable to operate and unable to transfer Pat Joe Walsh, staff in Monaghan in the early hours of that Friday morning continued to give him blood.
"They were putting it in and it was coming out through his mouth," his sister Phyllis Hughes recalls.
The first few hours of his bleeding were critical, doctors say, because after that he may not have been stable enough for a hospital transfer or even stable enough to be operated on.
The Walsh family believe Drogheda hospital should have taken him back at that point. Or more importantly, they firmly believe he should never have left Drogheda in the first place. Edward feels he was not fit for the transfer and that the journey from Drogheda possibly was to blame for causing his ulcer to bleed again.
MANY CRITICAL QUESTIONS will have to be answered by the Carey investigation. Prof Drumm, a hospital consultant for many years, suggested one of the crucial issues to be looked at is whether there was "consultant to consultant" contact in the different hospitals about this man.
The Irish Times understands the consultant on call in Monaghan that Thursday night didn't even know Pat Joe Walsh was in the hospital, having allegedly not been informed about his transfer from Drogheda until he had begun to bleed uncontrollably. And the lead surgeon in Drogheda, Finbarr Lennon, told The Irish Times last week he didn't know anything about what happened Pat Joe Walsh until he read a report of calls for an inquiry into his death in this newspaper last Saturday.
Communications failures will also have to be looked at by Carey.
Lennon was medical adviser to the former North Eastern Health Board for many years until reforms led to the abolition of health board structures almost a year ago. While in that position, he advised health board management that, in the interest of safety, emergency surgery should not be carried out in Monaghan. He said the hospital could no longer safely maintain a stand-alone, seven-day, 24-hour emergency general surgical service. The service was withdrawn and Prof Drumm is opposed to restoring it. He says it is unjustifiable in a hospital serving a population of about 60,000 people.
The Royal College of Surgeons in Ireland has been of the opinion that the hospital shouldn't do emergency surgery either but when asked this week about why some smaller acute hospitals such as those in Mallow, Nenagh, Ennis and Ballinasloe can do emergency surgery and Monaghan cannot, it said given the current investigation into Walsh's death it felt it would be inappropriate to comment at this stage.
Observers say, however, that the other smaller hospitals are not the same as Monaghan, which has just one permanent surgeon, backed up by two locum surgeons. Furthermore it does not have training recognition for junior doctors. "To run an acute surgical service you need basic requirements and they have less than other peer institutions in the rest of the country," one surgeon says.
The Medical Council, which polices the medical profession in the interests of protecting patients, won't comment on the Walsh case because the circumstances surrounding his death are not yet fully established. Dr John Hillery, the council's president, says, however, that as a general rule doctors are required to do what is best for patients and afterwards be able to stand over what they did. What they do will, he says, depend on their clinical judgment and the resources available to them. "It's not cut and dried."
Among the questions people have been asking since the tragic death of Pat Joe Walsh is why, in particular, did Cavan General Hospital not take him in when it was asked to do so? Some may wonder if it has to do with its feeling of being overrun by Monaghan patients without being adequately resourced to look after them. This is possible. Consultants in Cavan have been seeking ring-fenced surgical beds for patients for a long time and there is still no sign of them being provided. They recently joined with consultants in Monaghan in calling for Monaghan to be put back on call for emergency surgery. The appeal fell on deaf ears.
There's also the possibility that Cavan hospital felt it would be inappropriate for it to take in Walsh given that he required major gastrointestinal surgery on a duodenal ulcer and, under a protocol in this hospital, only one surgeon is allowed carry out this kind of surgery. It is understood the surgeon allowed to carry out this type of surgery was not on call on the night in question.
Two nights after the Walsh tragedy, staff at Cavan hospital objected to another patient who needed emergency surgery being transferred to the hospital from Monaghan. Staff in Monaghan got the manager of Cavan General Hospital out of his bed at 3am last Sunday to intervene. He directed staff in Cavan to accept the transfer of the patient.
In the end it seems the patient, who was transferred to Cavan, needed urgent vascular surgery which is not provided in Cavan at present and then had to be sent to Beaumont hospital. Doctors in Cavan say the fact the patient had to go to Beaumont in the end is proof the patient should not have been sent to Cavan in the first place.