A coroner today ordered the Health Service Executive to investigate a west Dublin nursing home after the body of an elderly patient was found in a shocking state.
An inquest heard that 98-year-old Elizabeth Donovan had severe ulcerations on her skin at the time of her death in Lucan Lodge Nursing Home.
The elderly woman, who weighed around six stone, had not been seen by a doctor for six weeks before her death on May 28th, 2006. She had been bedridden for six months. Her cause of death was recorded as pneumonia, with skin ulcerations, cystitis and dehydration
Dublin County Coroner Dr Kieran Geraghty said both an undertaker and pathologist had reported that Mrs Donovan had been in a 'shocking state', and that he could not close the case without alerting the authorities. However, Mrs Donovan's family told her inquest that they believed she had always been well cared at the home.
"There as such extensive ulcerations something should have been done about it," said the coroner, recording a verdict of misadventure. "She should have been seen by a doctor. "She must have been in great pain." The dead woman's daughters Nora and Gertrude said their mother was in pain by the end of her life. "She was in a little bit of pain at the end," said Nora. "Only in the latter part, she cried a bit.
"Otherwise she was very well looked after in the nursing home. "She was a very strong person in herself." Gertrude said she had seen nurses changing the bandages on her mother's legs.
"There was blood coming down them from little sores in her legs and the legs were black," she said. Nursing staff at the home maintained that although Mrs Donovan could not communicate, she was not in pain and slept well. They said her skin was fragile and susceptible to breaking, which is why she remained in bed, and that she frequently refused to eat or take supplements by closing her mouth or spitting them out.
Her legs were also wrapped in bandages to stop any friction between them. Junior nurse manager Gillian Lynch said Mrs Donovan's skin would tear with any touch and she had specialist bedding and bandages. "She was very comfortable," she said. "You could tell from her expressions. She wasn't crying out in pain." Julie Lewis Ashley, senior nurse manager, said Mrs Donovan's skin was so fragile that the hoist would damage it.
She said the nursing home was inspected by the HSE every six months, and had been routinely checked shortly after Mrs Donovan's death. Both nurses claimed when the doctor had seen Mrs Donovan she been suffering with the wounds which were referred to as ulcerations.
However, Dr Mary Boyd disputed their evidence. "I have no record of ulcerations, I have a record of bleeding from small lesions six weeks previously," she said. "I would have expected to be called back if it got worse." The inquest heard Mrs Donovan entered the home in 2002 after being treated in James Connolly Memorial Hospital, Blanchardstown, where she was kept in isolation for six months with MSRA and recovered.
Pathologist Dr Eamon Leen said she weighed only 35 - 40 kilos at the time of her death and was dehydrated and had muscle waste "Severe ulceration was found on the front and back of both her legs and her left forearm," he said. No-one from Lucan Lodge was available to comment tonight.