Pictured above outside Limavady Courthouse: The family of the late Mrs Brigid Cavanagh who say the Coroner’s findings today are ‘a damning indictment of the Western Health and Social Care Trust’.
A Coroner investigating the death of an 83-year-old Derry woman found dead on the floor of her hospital room in Altnagelvin Hospital has ruled that bed safety rails were not put up, despite evidence to the contrary from the Western Trust.
The findings were made today at the inquest into the death of Brigid Cavanagh of Foyle Park, who died on July 20, 2016.
She was found dead on the floor by her bed in the early hours of the day she was due to be discharged from hospital to go home.
After Mrs Cavanagh's death, it was discovered that she had also suffered a fractured femur that had gone undiagnosed.
Mrs Cavanagh had been suffering from 'end stage renal and cardiac failure' and was admitted to hospital after falling at home. She could not walk unaided and family believed she had dementia, however, this was undiagnosed.
The Western Trust apologised and admitted a number of failings in Mrs Cavanagh’s case.
Delivering his findings in the case, Coroner for Northern Ireland, Patrick McGurgan said: “There is absolutely no doubt that Mrs Cavanagh was very ill and there is absolutely no doubt that her family loved her very much; the devotion and care paid to her in the last years of her life – was truly remarkable. It was a credit to the whole family and I wish to acknowledge the dignity with which they conducted themselves throughout the process.
“Nothing I can say can bring your late mother back but my only hope is that the family gained answers to some of their questions. I fully understand the hurt felt by the family especially because no family member was with her at the time of her death but I hope you will take some consolation in knowing that she passed away very quickly.”
Mr McGurgan said that he acknowledged how the Trust had approached the case and commended the fact that they issued an apology at the outset. He said it was ‘very difficult’ for family members to sit through the evidence and for witnesses to revisit what had happened.
He added: “The two most recurring themes for inquests into deaths in a hospital are poor quality of notes and poor communication between medical staff and families.
“Greater and immediate attention needs to be applied to these areas and a vast improvement is needed in these areas to be of benefit to the families and staff.
“The Trust identified areas for learning and improvement and hopefully learning and improvement may bring something positive from this tragedy.”
In his findings, Mr McGurgan said that the ‘quality of notes was unacceptable’ and that vital information should be ‘entered immediately’ on admission to hospital.
He also said that ‘insufficient consideration’ had been given to a drop in haemoglobin requiring a blood transfusion and that this had been a ‘missed opportunity’ to spot the fact Mrs Cavanagh had a fractured hip. He said she should have been sent for a further scan when she could not bear weight on her hip and complained of pain.
Mr McGurgan also observed that a night manager on the ward had said Mrs Cavanagh should, ideally, not have been placed in the room she was in and that her ‘risk assessment could have been more accurate’.
He said that the writing of notes to reflect the work of a whole team rather than an individual was ‘completely unacceptable’ and that ‘notes should only be written and signed by the person who conducted the checks’. He also ruled that the words ‘cot sides up’ had been entered in a signature column as an ‘additional note’ and the nurse responsible had admitted she was unsure about when they were entered.
Mr McGurgan also criticised the fact that Mrs Cavanagh’s body was moved and lifted back into the bed before the Coroner’s office had been contacted; he said that this ‘dearth of knowledge and guidance was detrimental’. He also said that ‘insufficient consideration was given’ with regard to contacting family members when Mrs Cavanagh was anxious and lonely and had expressed on a number of occasions that she wanted someone to sit with her.
A total of nine recommendations had been made by the Western Trust in light of the lessons learned following Mrs Cavanagh’s death; some have already been implemented while others are in the process of being implemented. Mr McGurgan suggested that the new measures should be put in place ‘as soon as possible’.
He ruled that ‘on the balance of probabilities’ Mrs Cavanagh fractured her hip after a fall at home and this was not detected in hospital. He also ruled that she ‘suffered a terminal collapse while alone and she fell out of bed while the cot sides were down’.
Pictured above: The late Mrs Brigid Cavanagh.
Today, outside Limavady Courthouse following their mother’s inquest, members of the Cavanagh family wept and described the Coroner’s findings as ‘a damning indictment of the Western Health and Social Care Trust’.
Speaking on behalf of the family, Mrs Cavanagh’s son, Vincent, said: “The Cavanagh family would like to take this opportunity to thank the Coroner, Mr McGurgan, and his team for their efforts in trying to determine how our mother died in Altnagelvin Hospital. We understand that the remit of the Coroner is limited and the inquest cannot apportion blame.
“However, what we have heard this week has been a damning indictment of the Western Health and Social Care Trust.
“It was very difficult to hear but [the Coroner] vindicated all the concerns that we had as a family, they have clearly listened to all the evidence and have come to the conclusions that the family knew all along.
“Our mother had the right to care and dignity up until the time of her death and to have her family around her. This was denied to our mother and our opportunity to say a final goodbye was denied to us.
"We can only imagine the terror and fear that she experienced on her own, dying on the floor in pain. Her death in this way was preventable and avoidable.
“This should not have happened and should never be allowed to happen again to another vulnerable person or their family.
"From the time of our mother’s death, we have engaged with the Western Health and Social Care Trust and their Serious Adverse Incident Investigations. It is unfortunate that our experience has been that the Trust has chosen to put all of their efforts into covering up and trying to excuse their failures rather than be open, honest and transparent.
“Throughout it, the Western Trust have not been assisting us in trying to understand the circumstances around our mother’s death and have not been honest about all their own shortcomings.
“It knocks your confidence in the whole system; these are people who we entrust with our loved ones. The Western Health and Social Care Trust have a lot to answer for and we have no trust in the Trust.
“We call for the immediate implementation of a statutory Duty of Candour for the Health Trusts.”
Mr Cavanagh said that, despite the recommendations made and changes being made within the Trust, the family lack confidence after hearing a nurse admit in court she believed what happened to their mother could happen again.
“The family don’t have the level of confidence that [these changes] would make a significant difference if somebody in our mother’s position presented today to the hospital. One of the witnesses earlier in the week, when asked if the same thing could happen again, clearly said that they think it could happen again.
He added that there was ‘definitely an issue that has to be addressed in terms of the narrative or story the Western Health Trust tried to present’.
“It’s not what families like us need, if they had come out at the beginning and apologised and said, ‘We got things wrong’ instead of waiting until we were at an inquest and apologising – we acknowledge the apology but we want to know what exactly they’re apologising for.”
Mr Cavanagh said the family are carefully considering their next steps in light of the Coroner’s findings.
“The family is going to sit down and have a conversation, we are not going to do anything rash.
“We are going to let what the Coroner has said today sink in and try and understand it and we will decide over the course of the coming days and weeks what our course of action is going to be.”
Mr Cavanagh added: “Losing a loved one is difficult; the treatment of our family and the behaviour of the Western Health and Social Care Trust has been disgraceful.
“The Western Health and Social Care Trust should be ashamed of themselves today.”
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