Hazel O’Kelly came home on October 28th, 2005 to find her father Patrick, a 61-year-old security guard, distressed, incoherent and vomiting.
"He was never sick in his life, not up to then," she says of Mr O'Kelly, who was admitted to Mid-Western Regional Hospital in Limerick with a suspected stroke. His condition stabilised and he was able to sit out on a chair and chat to his family a few days later.
That was to be the last time his family saw him alive.
On the night of November 2nd/3rd, Mr O’Kelly fell from the end of his bed. The fall was not witnessed by the nurses on duty, but it was presumed he was trying to go to the toilet. He suffered a broken tooth, an 8cm laceration to the back of his head and cuts to his tongue. Early the next morning, his family was summoned.
“The doctor was asking dad if he recognised us,” she recalls. “He said, just like that, ‘Your father’s dying’.”
Mr O’Kelly’s condition deteriorated over the next 48 hours and he died in the presence of his family. Ward activities continued as normal and at one point a tea lady opened the curtain and said, “Is there breakfast here?” to the dismay of family members.
Less than two hours after his death, they were asked to vacate the ward, but Mr O’Kelly’s body remained in the bed for over six more hours. No postmortem was held and more than two weeks passed before the coroner was informed.
Ms O’Kelly was dissatisfied with the treatment her father received in the hospital and in particular with the assurance of doctors that his death was unrelated to the fall that had occurred.
Four-hour delay
Why was there a four-hour delay in notifying the family of Mr O’Kelly’s fall? Why were four different times recorded for the time of the fall in medical notes? Why wasn’t a skull X-ray carried out after his fall?
The family maintained there was no call bell on his bed, but the hospital disputed this. One nurse said the side rail on his bed was down, while the other said it was up.
Ms O’Kelly first complained to the hospital, which compiled an incident report she regarded as a whitewash. Still dissatisfied, she contacted a local solicitor who advised her to “walk away from it”. She wrote to politicians and then the head of the HSE, to no avail. An inquest was eventually held and an open verdict returned.
She contacted the Office of the Ombudsman, Emily O’Reilly, whose officials agreed to investigate her complaint.
Later, she got in contact with specialist medical negligence solicitors Callan Tansey, which began legal proceedings. Advocacy group Patient Focus also helped.
Right to a postmortem
The HSE explained the delay in contacting the family by telling the ombudsman his condition didn’t deteriorate immediately after the fall and when it did family members were phoned immediately. It apologised for the failure to advise the family of their right to a postmortem and agreed the coroner should have been notified on the day of his death.
The ombudsman sought the maintenance record for call bells for the month Mr O’Kelly was in the hospital, but was told there was no copy. Yet, the records for the surrounding months were available.
The ombudsman's report found the hospital was negligent or careless for its treatment of Mr O'Kelly's remains and his family on the ward, and for the non-availability of the maintenance records for the call bell. That report, published in 2010, did not identify the patient, but Ms O'Kelly subsequently took legal action against the HSE, which was settled without admission of liability in the High Court before Mr Justice Michael Peart last December.
After nine years, Ms O’Kelly still misses her father, who used to live around the corner. “If he hadn’t had that fall, he’d still be here,” she says.
