I thank the Ceann Comhairle for allowing me to bring to the attention of the House the death in Limerick Regional Hospital at 1.30 p.m. on 20 September 2002 of a 21 year old student who was found hanging by her dressing gown belt from a shower curtain support in a bathroom of the acute psychiatric unit in the Mid-Western Regional Hospital, Limerick.
I express our deep sympathy to the parents and brother of the patient who died and know that whatever reports are carried out will not bring back their beloved daughter and sister.
The patient suffered from severe depression from age 18 and on two occasions, one of which was the day following her 21st birthday, the patient attempted suicide. On 13 September 2002 she was admitted to St. Patrick's Hospital in Dublin without a full check by the hospital of her VHI cover, and it was found that the VHI did not cover her treatment. This forced the family to terminate the private treatment and to transfer her back to Limerick Mid-Western Regional Hospital. This should not have happened andher private insurance status should have been identified by the hospital prior to heradmission.
Despite the patient showing serious suicide risk, she was discharged into her parent's care, who travelled by train. If the patient was suffering from a serious general medical condition, the transfer would have been arranged by ambulance with medical back-up.
The consultant psychiatrist at St. Patrick's informed the clinical director of the Limerick Mental Health Services that there were concerns in relation to the patient's risk of suicide and that she was in a special care unit with 15 minute nursing observations. However, the treating consultant at the Mid-Western Health Board hospital had not been advised of a significant suicide risk. It is clear that communications regarding the patient between the consultants was insufficient, indirect and lacking in detail.
In his ward round on the morning of 20 September, the treating consultant failed to notice the hand-written letter to him from St. Patrick's Hospital, which contained concerns about the patient's current mental state and registered unease about the risk of self-harm, including details about medication that had ameliorated the patient's agitation and attendant subjective distress. The patient's life was at risk as a result.
The psychiatric nurse in ward 5B brought to the attention of the treating consultant that the collapsible curtain rails had become detached, but this was regarded as insignificant.
The report drew attention to the fact that the treatment plan was based on the clinical examination and opinion of two junior doctors without direct consultant assessment. The transfer material failed to outline the settings in which the patient was treated and the level of nursing intervention applying in St. Patrick's Hospital.
Serious concern is expressed regarding the trainee psychiatrist who admitted the patient. His psychiatry experience commenced two months previously in child and adult psychiatry but he had on-call duties for adult mental health. The report expressly states that a doctor of such limited training should not be rostered on a general adult psychiatry duty rota.
The documentation from St. Patrick's Hospital failed to identify that the patient had been cared for in a special care unit. The documentation was misaligned and in the case of some of the documents foolscap-sized material had been photocopied on to A4 sized paper with the loss of information including the letters CU appearing instead of SCU, which stands for special care unit. This would have alerted admitting staff to the patient's serious condition. The initial nursing assessment failed to read through the detailed clinical information forwarded from St. Patrick's, although these notes were available.
The absence of a high-observation area in ward 5B and a dedicated child and adolescent unit is identified as a serious deficiency in the facilities of the ward. Such facilities, if available, will contribute to the more efficient observation of patients in danger. The observation of Anne in her ward created difficulty for severely over-stretched nursing staff. At midday, two student nurses who had been detailed to observe her went off duty and a nurse detailed to observe another patient was asked to take over. She advised she was unable to do so. However, she was misinformed by another nurse who presumed that she had seen Anne in the dining room. It was not Anne, who, at approximately 1.30 p.m., was discovered missing and found hanging from a shower railing.