A nurse, who treated an 83-year-old Derry woman found dead on the floor of her hospital room in Altnagelvin, admitted numerous mistakes regarding the patient’s case saying, ‘I have no excuse’.
The admission came during the second day of 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.
During the ongoing inquest today, a nurse with 38 years’ experience who works in Altnagelvin Hospital and admitted the late Mrs Cavanagh to hospital, confessed she had made a series of errors.
She had filled out documents pertaining to the care and condition of Mrs Cavanagh and admitted: “I ticked every box wrong.”
In questions asking whether relatives were interested in being contacted for ‘one to one care’ if their mother needed it when nurses were busy, the nurse ticked ‘no’.
She also ticked ‘no’ to questions asking whether Mrs Cavanagh was confused or needed a low bed or sensor if at risk of falls. The nurse also left review dates blank and failed to pick up on all her mistakes during the handover to other nurses at the end of her shift.
The legal representative for the Coroner said: “How can this family or members of the public be reassured when all the wrong boxes are ticked in a fall assessment and then the patient is found on the floor?”
The nurse said: “I take full responsibility, it was an error of judgement on my behalf. It was a very busy acute medical unit – it was simple error. I was near the completion of a night shift when she was admitted.”
Coroner for Northern Ireland, Patrick McGurgan said: “What you’re telling me is that you said this patient was not in the state of health she clearly was in – that’s a glaring omission.”
The nurse replied: “She had been in casualty for nine hours, she was tired, she just wanted to get to bed.”
Pictured above: The late Mrs Cavanagh
Mr McGurgan said that respected the nurse’s honesty and that a mistake could be made but that a number of mistakes had been made on two separate important documents. He added: “With the greatest of respect, I don’t understand how that could’ve happened – it is the complete opposite information.”
He added that, given what he had heard, pressure was ‘getting worse’ for the National Health Service and that ‘there is a greater opportunity of things like this happening’.
The legal representative for the Western Trust asked if the errors happened because the nurse ‘couldn’t be bothered’. She said this was not the case and that it would take up to 30 minutes to fill out these details.
He replied: “It took you no time at all, you just put ‘no’ to everything. One document would be careless or unfortunate but two…is this a bit of a habit of yours?
“You do realise that the patient’s records are highly important for her care and what happened to the patient?”
The nurse replied: “She was found dead out of bed.”
She added: “I have no excuse – the facts are there in black and white. The only thing I can say is it was a busy ward.”
A doctor who gave evidence at the inquest also admitted Mrs Cavanagh’s fractured hip had gone undiagnosed and that, given her complaints of pain and a physiotherapist expressing concerns it may be broken, she should have been given a scan.
He also said her oxygen levels should have been monitored more closely and oxygen increased during a period where they had dropped.
The doctor claimed that Mrs Cavanagh was due to be discharged but that there had been a multidisciplinary meeting about her care.
He said that care would have been ongoing after her release and that she would have been recalled for a CT scan. However, none of this was documented or relayed to the family.
Mr McGurgan said: “There was no mention of a CT scan, no meeting and she was to be discharged after being stabilised by a blood transfusion.
“One of the most shocking points of this inquest is that the Cavanagh family were expecting their mother to be discharged to go home and the next thing they got was a phone call to say she was dead.”
The inquest continues.
Pictured above: Paul and Vincent Cavanagh, sons of the late Mrs Brigid Cavanagh, pictured outside Limavady Courthouse earlier today attending the inquest into their mother's death.
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