Hospital criticised for failing to tell coroner of suspicious death

Limerick University Hospital failed to notify a coroner of the suspicious death of a patient, as it is obliged to do so by law, an inquest has heard.

Limerick coroner Tony Casey said he only learned of the death of a 63-year-old woman who was admitted to the hospital from a nursing home five days after she had passed away, and after her funeral.

Dr Casey said it was too late to order an autopsy with the Health Information and Quality Authority told him of Kathleen O’Doherty’s death.

Recording an open verdict, Dr Casey said it was a suspicious death, and it should be brought to the attention of the hospital that anything suspicious about a death should be reported under law to a coroner.

“I received a report of the death from Hiqa five days after the deceased died and there was no postmortem, because she was buried at that stage,” said Dr Casey.

Ms O’Doherty was cared for at Cahermoyle nursing home, Ardagh, Co Limerick.

Nurse Maria McLoughlin said she was giving out medication to patients on Jan 23.

Ms O’Doherty was alone in the dining room and Ms McLoughlin gave her medication.

Shortly after, she learned Ms O’Doherty had fallen in the smoking area and went to her assistance. The patient was conscious, but groggy.

Shannon Doc was notified and a doctor came to see Ms O’Doherty

Ms McLoughlin said she was called to attend another patient and locked the drugs trolley. There were two small pods containing medication, which she put on top of the trolley and covered with a box of disposable tissues. She subsequently discovered the pods of tablets were missing.

As Ms O’Doherty was being taken to hospital, Ms McLoughlin told the doctor the missing drugs were something that should be factored into the information the hospital got on Ms O’Doherty’s admission.

In reply to Ciara Daly, BL, for the O’Doherty family, Ms McLoughlin said the drugs in the pods would have had a sedative affect on whoever took them. The missing pods with the drugs were never found.

Geriatrician Margaret O’Connor said she had been treating Ms O’Doherty at University Hospital Limerick for several serious conditions, which had worsened during 2012.

She said a toxicology urine test for one of the medications in the missing pods proved positive, but this medication was also prescribed for Ms O’Doherty.

Asked by Ms Daly what affect the missing drugs would have, Dr Casey said this was a hypothetical question as there was no proof as to who took the pods.

He said it was unfortunate that the pods containing the drugs were left unattended. As it was not known what happened these drugs, he recorded an open verdict.

As well as criticising the hospital for failing to alert a coroner, Dr Casey also recommended that drugs should not be left unattended when being administered.