Family of elderly Corkman seek investigation into death after 10 falls in care home

Regina Nolan, daughter of Noel O’Sullivan, at the inquest into his death. Picture: Michael MacSweeney/Cork Courts

The family of an elderly man who died after suffering serious head injuries in his 10th fall at a nursing home in eight months wants Hiqa to investigate nursing home falls more closely.

Noel O’Sullivan, 93, from Ballinlough, Cork, fractured a hip, a wrist, and suffered traumatic head injuries in his 10th and final fall at the Bon Secours Care Village on the Lee Road in Cork at around 2am on October 12, 2020, the Cork City Coroner’s Court was told.

But coroner Philip Comyn heard how nursing and care assistant staff did not identify the injuries and put Mr O’Sullivan back to bed, with painkillers.

It was six hours before he was examined by a doctor, who ordered his transfer to Cork University Hospital (CUH), where he died six days later.

His family were contacted as the transfer was being organised despite having specifically to be contacted immediately in the event of a fall.

Assistant State pathologist, Dr Margaret Bolster, said the cause of death was traumatic brain injuries due to a fall.

Four of Mr O’Sullivan’s children — Gerard, John, Orla, and Derek — said they accept that Covid-19 was a complicating factor but that it cannot be used as an excuse for not informing them immediately about their father’s fall, or for the delay in his transfer to hospital.

Family statement

“It is a terrible and haunting piece of knowledge to know that our father was in terrible pain for the long hours before his hospital treatment,” they said in a statement.

Mr O’Sullivan’s daughter, Regina Nolan, who had been her father’s primary carer, said he suffered 10 documented falls in the care home between March 25 and October 12 — many were unwitnessed, several were not notified to the family.

Nurse Joy Daly said she found Mr O'Sullivan lying face down on the floor of his room at 2am on October 12.

She said he had a graze on his forehead, and complained of pain in his left shoulder and left leg.

Following a physical examination, Ms Joy and colleagues put him back in his bed, gave him painkillers, and contacted SouthDoc by phone soon afterwards to discuss the incident.

SouthDoc's Dr Antonias Issai, who told nursing staff to monitor Mr O’Sullivan’s condition, told the inquest that he was not told at the time about Mr O’Sullivan’s head or wrist injuries.

The inquest was told that when GP Dr Edward O’Sullivan visited the care home at 8am, he ordered Mr O'Sullivan's transfer to CUH where the full extent of his injuries became apparent.

New post-fall protocol

Director of nursing, Catherine O’Mahony, who took up the position after Mr O’Sullivan’s death, said she reviewed the case files, and said a new post-fall protocol has been developed for residents who suffer major or serious injury, under which Mr O’Sullivan would have been sent by ambulance to an emergency department.

Mr Comyn recorded a verdict of accidental death and issued a number of recommendations, including that the care home review its communications protocols with families, and he urged the care home and SouthDoc to review its systems to ensure there are no “information gaps”.

Speaking afterwards, Ms Nolan said she contacted Hiqa following her father’s death and was disappointed when it said it does not investigate individual fall cases.