I am grateful for the opportunity to raise this most sensitive matter of the death, by suicide, of a 21 year old student while a patient of the Mid-Western Regional Hospital on 20 September 2002. First, I wish to sympathise with the father, mother and brother of the suicide victim. The death, as in any suicide, has been deeply traumatic for them. I also recognise the trauma of the staff of the Mid-Western Regional Hospital and recognise that the death has a deep effect on the service providers.
The family and I are demanding that the Minister for Health and Children should immediately set up an independent investigation into the circumstances surrounding the tragic death of this young girl. It is not acceptable that the Mid-Western Health Board is the investigating body of itself. There are serious questions of hospital practices, procedures, safeguards and suicide prevention protocols, including ensuring that the control of suicide opportunity is recognised as a key area of prevention. I disagree fundamentally with any internal review by a health board of the facts surrounding a tragic incident, assessing the adequacy of procedures in place to ensure safe patient care, and making recommendations to itself on necessary changes.
In this respect, I refer to the report of the independent review panel to the Minister for Health and Children concerning the birth of baby Bronagh Livingstone on 11 December 2002 in the North-Eastern Health Board area. The conclusion of the NEHB report was that the decision to transfer to Cavan General Hospital was the right one, given the condition of the mother and the prevailing conditions on both sites. However, it was the view of the independent review panel that the birth of the baby was imminent shortly after the mother arrived at Monaghan General Hospital and that, consequently, no attempt should have been made to transfer Ms Livingstone to Cavan General Hospital.
On 20 September, the 21 year old student entered a shower around 1 p.m. and was discovered hanging on a shower rail by a dressing gown cord. She was cut down by nurses and a cardiac team was called. She was pronounced dead at 1.55 p.m. The deceased had been admitted the previous night, having been transferred from St. Patrick's Hospital, Dublin. She was diagnosed as depressed and suicidal and had attempted hanging twice. A senior nurse checked the patient at around 9.45 a.m. and asked a student nurse to observe her. The senior nurse took her break around 9.45 a.m. to 10 a.m. and, on returning to the patient's room, she noticed that the curtain rail had fallen down. The deceased denied interfering with the curtains. The nurse expressed concern to the clinical nurse manager that the curtain of the dormitory had fallen and that this may have been caused by a patient, which might indicate cause for concern. She also spoke to the deceased's psychiatrist and expressed her concern.
When the senior nurse called to observe the patient later, she found her locked into the shower. With difficulty she opened the door and, although the patient said she was all right, she appeared to be anxious, fretful and frightened. The senior nurse again requested two student nurses to stay with the patient. The students finish work each Friday at 12 noon. Was it because of the demand on nursing staff in the unit that there was no one available to give special attention to the deceased? When the senior nurse checked the deceased's room later, she was not there. She may have attended the dining room at lunch time.
The two nurses who discovered her body had been working since morning and had seen the girl at about 12.30 p.m. to 12.45 p.m. She had been missed from the ward and a search was conducted. It was noticed that the shower room was locked. The two nurses tried to open the door but failed to do so as it was locked from the inside. They had difficulty opening the door and scissors had been used to turn the lock. The girl was hanging from the shower curtain rail by a shower robe cord. She was discovered at about 1.30 p.m. The findings at the autopsy were consistent with cardio-respiratory failure due to asphyxia due to constriction of the neck by a ligature.
The family demands and, in my opinion, is entitled to an independent review. If this death had the same profile and public disquiet surrounding it as the death of baby Livingstone in Cavan Hospital last December, I have no doubt there would be an independent inquiry to review all aspects of the tragedy. I ask the Minister to ensure that such an inquiry is established. In the Cavan case, an independent inquiry proceeded at the same time as the internal inquiry. In this case also, an internal inquiry should not preclude an independent inquiry. I look forward to the Minister of State's reply.
