A husband thought he was doing the right thing by rushing his beloved wife back to Cork University Hospital’s (CUH) mental health unit after she overdosed. He thought the unit’s medical staff, who had been caring for her earlier, could organise the urgent care she so desperately needed.
But Henry O’Reilly’s decision has haunted him for the last year.
Remarkably, it resulted in his wife Marion having to wait in CUH for almost 45 minutes for an ambulance to drive 40km from Fermoy in North Cork — to transfer her about 800m, or 90 seconds, to the hospital’s emergency department (ED).
“This decision was the worst of my entire life and will haunt me till the day I die. I am constantly wracked with guilt as I feel if I had gone to ED, she would be alive now,” Mr O’Reilly said in his statement to Cork City Coroner’s Court yesterday.
Coroner Philip Comyn was told that Ms O’Reilly, 61, from the Lough, Cork, had suffered from periodic bouts of manic depression for the last 30 years, and had been hospitalised several times.
She was hospitalised after an overdose in January 2016 and was later admitted to CUH’s mental health unit, opened in August 2015, where she remained for about 10 days before being released.
She was visited by a home care team which became concerned about suicidal ideation and Ms O’Reilly returned voluntarily to the mental health unit in late January.
But she was deemed well enough on March 5 last year to be allowed home for a few hours that afternoon.
Mr O’Reilly said he went to check on her around 3.30pm and found her upstairs in bed having taken a massive overdose of some of his prescribed medication. She could have taken up to 200 tablets.
On the drive to CUH, Mr O’Reilly said his wife told him she regretted taking the overdose.
They arrived at the mental health unit around 3.40pm.
Dr Vilma Maria Vera Pezo said she gave Ms O’Reilly oxygen, arranged for her vitals to be monitored, and asked the unit’s nursing staff to arrange an ambulance urgently to transfer her to the ED on the far side of the hospital campus.
Ambulance control tasked an ambulance from Fermoy at 4.08pm and gave the unit’s medical staff a phone number to contact if the patient’s condition deteriorated while they waited for the ambulance.
Dr Pezo said while Ms O’Reilly’s oxygen levels improved and her vitals were stable, she said this was a “life-threatening condition”. She also said staff tried to contact the phone number several times but it went unanswered.
Mr O’Reilly said Dr Pezo would not allow him take his wife in his car to the ED, nor would she allow a security guard who offered to take her because of the hospital’s patient transfer protocol.
“An ambulance was the safest way to transport her. That was the right thing to do,” Dr Pezo told the inquest.
But Mr O’Reilly said over the next 55 minutes, the unit’s staff told him the ambulance would be arriving soon, that they could hear it coming, or that it couldn’t be much longer.
“Because of this I felt pressured to wait, instead of just grabbing Marian, putting her in the car, and making the 90-second journey myself,” he said.
The ambulance arrived at the unit at 4.48pm, an hour after Ms O’Reilly had presented.
Paramedic Andrew McCrea said she was alert and they transferred her within two minutes to the ED where she was admitted just before 5pm.
But Mr O’Reilly said his wife was barely able to say “one or two words, having deteriorated while sitting in the unit for over an hour without any treatment whatsoever”.
“A&E did their best and put Marian in the resuss ward and about midnight she was moved to ICU and we were told she had a slight hope that she might survive. But, at 4am, her organs began to fail and they let us know that she was likely to only last for a few hours,” he said.
She was pronounced dead at 11.45am on March 6 last year with Mr O’Reilly and her two sisters by her side.
In his statement, Mr O’Reilly said relying on an externally sourced ambulance to transfer urgent cases from the mental health unit to the ED “displays incompetence of the highest level”.
“If Marian had been a patient in the old GF mental health ward, she would have been in A&E in about 30 seconds,” Mr O’Reilly said.
But assistant state pathologist Dr Margot Bolster said there were toxic levels of several drugs in her system, with the levels of one drug alone enough to cause death.
She said the ambulance delay was not a factor in her death.
Consultant psychiatrist Dr Eamonn Maloney, clinical director of the mental health unit, said such emergency transfers between the mental health unit and CUH’s ED are rare — occurring about three times a year. He said the patient transfer policy has been revised since Ms O’Reilly’s death to allow transfers using a hospital gurney or trolley, a change which now gives flexibility to clinicians in terms of decision-making on the ground.
The new protocol says gurney transfers can be considered where “awaiting ambulance transfer is deemed a timely risk”.
But he said such transfers carry risks, and that using an ambulance is still the only safe way to transfer urgent medical cases given the medical equipment on board and the high level of training of paramedic staff.
Mr Comyn said he was satisfied from the evidence that Ms O’Reilly regretted the overdose, and he recorded an open verdict.
He told her family there was little they could have done to foresee the overdose, or to prevent it.
And addressing Mr O’Reilly, he said: “It is also clear from the evidence the fact that you went to the mental health unit rather than ED made no difference.”
Speaking afterwards, solicitor Catherine Kirwan, said Mr O’Reilly and his family drew some comfort from the coroner’s comments, and also from the fact patient transfer protocols have been revised.
Coroner urges ambulance to release audio
The Cork City coroner is to write to the National Ambulance Service (NAS) urging it to release to a HSE review team audio recordings of calls made to ambulance control about Marion O’Reilly’s care.
Philip Comyn also said he found it “extraordinary” that a ‘doctor phone number’ provided by ambulance control to medical staff at CUH’s mental health unit went unanswered on up to six different occasions as they waited for an ambulance to arrive.
“I find that extraordinary and I will be looking for an explanation,” he said.
He said he accepted medical evidence that an ambulance was required for Ms O’Reilly’s transfer and he welcomed changes to patient transfer protocols.
However, he said he will be writing to the NAS urging it to assist the HSE team which is still conducting a full systems analysis in the wake of Ms O’Reilly’s death.
Michael O’Sullivan, the area director of nursing in Child and Adult Mental Health Services, told the inquest that he was asked last April to chair a review team to investigate all the circumstances surround this case.
However, he said that, at the time, the team comprised of just two people.
He said he asked for the team to be expanded to include experts in a range of other specialities, and that it was last September before the full team was in place.
The team, which first met on September 16, has taken statements from several individuals, he said.
They have yet to interview psychiatrist Mary Okafo, who is now practising in the US, a medical registrar involved in the case, or Ms O’Reilly’s husband, Henry.
Mr O’Sullivan said he hopes to interview Dr Okafo by phone over the coming weeks.
Mr O’Reilly said he plans to engage with the investigation team now that the inquest has concluded.
Mr O’Sullivan said while the NAS has provided some information to the review team, it has directed to communications group BT all queries about the audio recordings of key phone calls made to ambulance control.
He cited previous legal difficulties linked to consent on the release of such information as possible reasons for the delay in the release of the audio relevant to Ms O’Reilly’s case.
Mr Comyn said he hopes his intervention will assist the investigation.
Mr O’Sullivan said he hopes the review will be concluded by May.
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