A WOMAN died at Roscommon County Hospital last February having fallen down a flight of seven stairs in a wheelchair at the hospital six days earlier, an inquest has been told.
Prof Michael Farrell, consultant neuropathologist at Beaumont Hospital, Dublin, said Ann Macklin (52), Tibarney, Four Roads, Co Roscommon, sustained a significant head injury in the fall at the hospital on February 15th.
The injury was not the immediate cause of death but contributed to it, Prof Farrell told an inquest in Ballaghaderreen, conducted by coroner Desmond O’Connor. Evidence was given that the victim, who had multiple sclerosis, sustained a fractured eye socket, a dislocated shoulder and required a number of head stitches following the fall.
She contracted pneumonia later and died at the hospital on February 21st.
Prof Farrell said Ms Macklin’s MS was relatively inactive but she had been the victim of an old, large stroke which had caused weakness in her left arm and left leg. It was his opinion that Ms Macklin would not have died if she had not fallen down the stairs.
At the time of her fall, Ms Macklin had been a patient at St Coman’s Ward, a high-dependency unit. It had been planned to discharge her back to the care of the Brothers of Charity the following day.
Nurse Olivia Martin said the victim was lying on her side after the fall and was moaning but alert. She was bleeding from the right side of her forehead. After consulting the nurse registrar, Ms Martin and a porter brought Ms Macklin back to her ward.
Patricia Morgan, clinical nursing manager at the hospital, told Jeananne McGovern, for the HSE, that new measures had been put in place to ensure such incidents never happened again.
These included restricted access to certain areas of the hospital, the use of a swipe card system and locked doors, a new protocol for assessing patient falls and a review of the use of wheelchairs.
An inquest jury returned a verdict of death by misadventure.
The medical cause of death was given as bilateral bronchial pneumonia. The recent cerebral injury (sustained in the fall) could not be ruled out as a contributory cause of death.
On behalf of the jury, foreman Michael Scally conveyed three recommendations to the coroner.
The first was that access to patients with special needs be made available to carers and family members during periods of lockdown such as when an outbreak of the winter vomiting bug occurs. It also recommended that the hospital install a CCTV system along corridors to prevent incidents like this happening again and that the hospital reconsider repositioning the nurses station at the entrance to wards.
Expressing sympathy with Ms Macklin’s family over “a very unfortunate incident”, the coroner said it wasn’t known how she came to be on the stairs. “She may have been trying to turn at the top,” Mr O’Connor said. “It is very unlikely she came straight forward and down the steps”.
Following the hearing, Bríd Miller, solicitor for the Macklin family, welcomed the inquest finding of misadventure.
She stressed that the family bore no ill towards anybody as a result of what had happened.