The matter before the House relates to the actions of persons outside the House who are defenceless against allegations made under privilege. Accordingly, Members should exercise discretion in their contributions and persons outside the House should not be referred to by name or in a way which makes them identifiable.
Adjournment Debate. - Hospital Patient Death.
I have received the permission of the family in this regard. Mrs. Mary Ellen Butler, Clogher, Hollymount, County Mayo was taken by a health board ambulance to Castlebar General Hospital, on 18 February 1992 with what seemed like a routine 'flu. She had never been in hospital before and all her life enjoyed robust good health. She was visited in unit C in the hospital by her son, Michael, and his wife, Julia, at approximately 7.30 p.m. that evening. The Butlers were alarmed that her condition had deteriorated considerably from the time she left home by ambulance earlier that day. Mr. Butler's brother, P.J. and his wife, Tina, were also present. The Butlers allege that on examination of the chart at the end of the late Mrs. Butler's bed they noticed that the name on the chart was Mary Butler, not Mary Ellen Butler. They also allege that the chart stated that she had received insulin and morphine.
The following day, 19 February 1992, the late Mrs. Butler's daughter-in-law, Tina, went to the hospital at approximately 11 a.m. to discover that the patient had been transferred to the intensive care unit. Mrs. Tina Butler met with a nurse and stated that the patient had been receiving insulin and that this was recorded on the chart at the end of the bed. According to Mrs. Tina Butler the nurse responded that there was no need to worry, that "Mary was on insulin before".
Mr. Michael Butler and his wife, Julia, visited the hospital at 7.30 p.m. where they met the other members of the family who relayed what the nurse had said about the insulin. They went to the intensive care unit to ask if a mistake had been made in the patient's name. They were asked to wait outside the door of the intensive care unit and were told eventually by a nurse that a mistake had been made. They were ushered to a waiting room where they were visited eventually by a doctor who assured them that the patient had not been given insulin, that she had a minor heart problem and that everything would be okay.
The following morning, 20 February 1992, Mr. Michael Butler went to the hospital again where he eventually met the hospital administrator to whom he relayed the full details of what he had seen on his mother's chart on the night of admission. He also met the matron and discussed the matter with a hospital doctor. According to Mr. Butler at 7 p.m. that evening the family GP came to the Butler home and remonstrated with Mr. Butler insisting that he refrain from making any further allegations about what he had seen in the hospital. The family members went to the hospital again that night to find that the patient's condition had worsened. The Butlers allege that they sought but were refused access to a doctor.
On 21 February 1992 Mr. Michael Butler met the hospital administrator again and demanded to know what had happened in terms of the treatment and identification of his mother. He then consulted his solicitor who wrote to the Minister for Health, Dr. John O'Connell, demanding that the matter be investigated. Dr. O'Connell asked Mr. William Moran, programme manager, general hospital care, Western Health Board, to investigate the complaints.
Mr. Moran wrote to the Butlers' solicitor on 13 April 1992 stating that he had investigated the matter and that the late patient "did not require or receive insulin at any time during her hospital stay". Mr. Moran acknowledged in his letter that "it is correct that the records of another patient were referred to but within a short period the mistake was recognised and immediately rectified". According to the Butlers the so called "short period" was from 3 p.m. on 18 February 1992 to 8 p.m. on 19 February 1992 — a timespan of 29 hours. The Butlers maintain that the mistake was only discovered because of the persistence and questioning of the family members.
Because of his anxiety and because of what he had seen and the hospital's admission Mr. Butler insisted on seeing the charts and notes relating to his mother's hospitalisation. In July 1992 Mr. Michael Butler with his general practioner visited the hospital to inspect his late mother's hospital charts and records. In his reply to the question I tabled for a written reply on Tuesday, 19 April the Minister stated that "the medical officer was satisfied with the inspection". Whatever about the general practitioner, Mr. Michael Butler was far from satisfied. His solicitor wrote to the health board on 24 July 1992 stating "our client is quite satisfied that all the charts were not produced and in particular that one chart which is the subject matter of the entire correspondence was not produced".
In his reply the Minister admitted "there was a mix-up of notes between the patient in question and another similarly named patient". This is a serious admission. With whose notes were they "mixed up"? The Butler family believe that they were mixed up with those of another Mary Butler, who is a diabetic, who had been hospitalised previously at Castlebar Hospital, who was not a patient in the hospital at that time, who was on daily doses of insulin and who is happily still alive. This allegation has been made by the Butlers. Neither the Minister nor the health board have denied or refuted this. If the Butlers' assertion is correct and Mary Ellen Butler, so far as the hospital authorities are concerned, for the first 29 hours of her hospitalisation was not Mary Ellen Butler but Mary Butler, a diabetic on daily doses of insulin, then she must have been given insulin. To have omitted giving her insulin would have constituted an omission of treatment essential to her condition. If Mary Ellen Butler was treated, as the Butlers allege, as Mary Butler, in other words, if she was treated for something she did not have, this is an extremely serious matter.
Mrs. Mary Ellen Butler died on 8 August 1992 having spent further weeks hospitalised at University College Hospital, Galway and the Western Health Board hospital in Ballina. According to the death certificate she died from pneumonia, brain failure and para-thyroidism. It is not sufficient or acceptable that the serious complaints made by the Butler family should be examined by a serving official of the Western Health Board against whom the complaints have been made.
I want a full and detailed inquiry — the family are entitled to this — to be carried out by a competent and independent person into all aspects of the case. That investigation should determine and disclose the identity of the person whose notes were substituted for a 29 hour period for those of the late Mary Ellen Butler. It must then establish the medication which was appropriate to the patient whose notes were being used for Mrs. Butler and the precise medication used. It must also establish the number of hours which elapsed from the time of the late Mary Ellen Butler's admission to the General Hospital, Castlebar, the precise date and time the error of mistaken identity was discovered and the circumstances surrounding the discovery. Each official and medical individual who came into contact with the late Mrs. Butler from the time of her admission to the time she died must be interviewed.
I am not pointing the finger of blame at the medical and nursing staff at the hospital who are working in extremely overcrowded conditions and under severe pressure. However, mistakes occur and did in this case. The family are not interested in revenge or retribution; they want the truth and that is the least to which they are entitled.
The Deputy will be aware that the medical reports pertaining to the patient were examined by the patient's son, accompanied by the patient's general practitioner. The general practitioner spoke to the hospital consultant concerned and was satisfied with the inspection of the medical records.
Following further communication between the patient's son and the Western Health Board, the board invited the patient's son to nominate a second medical officer, if he so wished, to view the records. This invitation has not been availed of.
On a point of order, it would have cost £50 for a second examination.
I sought and received from the Western Health Board a detailed medical report on the deceased. Following an examination of this report I am satisfied that while there was a temporary mix-up in the patient's notes this was rectified quickly and the patient did not suffer as a result.
I am satisfied that this patient's hospital treatment was of a high standard which was appropriate to her condition. In the light of the specific information provided by the Deputy in the House tonight, I will have the matter reviewed.
Deputy Eamon Gilmore was selected to raise a matter on the Adjournment. However, I understand the Deputy is unavoidably absent and wishes to extend his apologies to the House, the Minister and the Department concerned.
The Dáil adjourned at 5.15 p.m. until 2.30 p.m. on Wednesday, 4 May 1994.