Breege Kennedy, aged 74, of Seafield Rd, Clontarf, Dublin 3, was suffering from weight loss, anorexia, and mild depression when she was referred by a GP to St John of God Hospital in Stillorgan.
It is thought she died at least a week before she was found at her home, where the curtains were drawn and a suitcase was left in the hallway, along with documents from her GP. She was last seen alive at around 10pm on September 12 at the Davenport Hotel with a friend.
Dublin Coroner’s Court heard that more than seven days passed before a referral letter from GP Patrick Lee requesting an urgent admission for Ms Kennedy was acted upon.
The letter was dated September 10 and was sent by fax. It arrived to the hospital’s main office instead of the admissions unit and subsequently “went astray within the hospital”.
Ms Kennedy, who was first admitted to St John of God in 1984, was well known to staff and would often phone and ask to be admitted.
However, following the retirement of consultant psychiatrist Rory Shelley, she told a friend the admissions process had changed and a referral letter was required. Richard Blennerhasset, consultant psychiatrist and clinical director at St John of God, said Dr Shelley’s retirement led to “some of the difficulty surrounding the handling of her case”.
“I have to acknowledge that this referral did go astray within the hospital and this was a terrible outcome,” said Dr Blennerhassett.
The faxed letter was placed in the hospital’s internal mail system and sent to the outpatients department.
“Sadly, by the time it was identified that admission was required, it would appear that the situation was already too late.”
Clinical psychiatrist John O’Donovan first saw the letter on September 15 and marked it to be followed up by his secretary, but this did not happen, the court heard. When he next saw the letter, on September 20, he tried calling the patient, but there was no answer.
He was “horrified” when he became aware of her death, he said.
New hospital procedures introduced since Ms Kennedy’s death include the scanning to an electronic patient record of all incoming faxes referring to admissions, appointing additional staff with responsibility for tracking all incoming referrals, and the installation of an upgraded phone system to ensure all calls are answered.
Ms Kennedy was found dead at her home on September 22, 2014. Death was thought to have occurred around September 12.
Coroner Brian Farrell returned a verdict of death by suicide.