Family of showband musician who died after nursing home fall criticises Hiqa

Regina Nolan at home in Ballinlough, Cork, with a portrait of her late father Noel O'Sullivan. 

The last thing Regina Nolan did for her father Noel O’Sullivan, was to carry his coffin.

Days before, the last thing she asked him was: 'Could he look out for her from heaven?'

Regina gets emotional when she remembers her 92-year-old father’s response.

“He looked at me and he was puzzled,” she recalls between anguished sobs.

“And as I held his hand in mine, he asked me: ‘Why would you say that?’ He really had no idea. He just wasn't ready to die.

“I said in reply to him, joking with him, ‘you’ve had an ould fall, ya divil’. He didn't say anything. He just stared back at me in silence.

“I don't even really know where that question came from, asking him to look out for me from heaven. I suppose something inside me knew I wouldn't get the opportunity to speak to him again and it just came out of my mouth.”

Noel O'Sullivan had been a resident of the Bon Secours Care Village.

Cork City Coroner Philip Comyn recorded a verdict of accidental death at the former Skyliners Showband musician’s inquest last Thursday.

He had been a resident of the Bon Secours Care Village when he fell in the early hours of October 12, 2020.

Care staff who put him back in bed shortly afterward did so after a very brief consultation with a SouthDoc GP over the phone.

Mr Comyn heard Mr O’Sullivan was finally physically examined six hours later by a doctor who immediately ordered his transfer to Cork University Hospital.

It took the home seven hours to notify Regina he had fallen and that, as well as suffering a head injury, he had also broken his left hip and left wrist.

This was despite the fact that the home had been specifically asked to immediately contact the family in the event of any accident.

The fall Mr O’Sullivan suffered before he died was one of up to ten he endured in the short time he was in the home from March until October 2020.

Two of them, including his last fall, had required the pensioner — who had dementia, a range of mobility issues and was a high falls risk — to be hospitalised.

A new post-fall protocol at the home has been developed for residents who suffer major or serious injury since the death of Mr O’Sullivan, of Old Blackrock Rd, Cork.

Mr Comyn recommended that Lee Road care home review communications protocols with families and with out-of-hours GP service, SouthDoc, to ensure there are no “information gaps” in future.

Mr O’Sullivan’s death certificate states he died from a “traumatic brain injury ... due to a fall”.

Regina Nolan with a pllow made from her late father's pyjamas. 

The day after her father fell, Regina rang the Health Information and Quality Authority (Hiqa) and asked the health watchdog to investigate.

She says she was told no, because Hiqa did not investigate individual complaints.

She was so shocked she hired Marian Fogarty, of Cantillons Solicitors, to take on her case instead.

“What is the point of Hiqa if it can't investigate individual complaints?” she asked.

“I couldn't believe it when they said they wouldn’t investigate.

Just how serious does a case have to be before Hiqa investigates a complaint about a nursing home?

Regina has since found out that just weeks before her father died, Hiqa passed the home as fully compliant in almost all the regulations it was inspected for.

At the time of the May 28, 2020, inspection, Mr O’Sullivan had suffered four falls and all but one had gone unwitnessed. 

The one that was witnessed was seen by a cleaner, and not care staff.

Her lawyer, Ms Fogarty said: “In my opinion, Hiqa’s inspection methods leave open the potential to miss serious safety issues.

“By the time Hiqa inspected the Bon Secours home, Mr O’Sullivan had already suffered four falls yet its subsequent inspection report found ‘good quality care was delivered to residents.’ 

“The report also found evidence that staff received training appropriate to their roles which enabled them to provide evidence-based care to residents."

She said the findings contradicted the facts and evidence heard at Mr O'Sullivan's inquest, adding she found it "astonishing" that Hiqa does not investigate individual complaints. 

“This contradicts the Health Act which states Hiqa can investigate if they believe there is a serious risk to the health and welfare of a nursing home resident,” she said.

Just weeks before Noel O'Sullivan died, Hiqa passed the nursing home as fully compliant in almost all the regulations it was inspected for.

Majella Beattie, of advocacy group Care Champions welcomed the Coroner's recommendations on communications between nursing homes and family members.

“The concerns around communications between the home and the family and the medical profession in Noel O’Sullivan’s tragic case mirror those we always hear from families," she said, adding that Hiqa's refusal to investigate Mr O'Sullivan's case was "deeply disturbing".

“Hiqa’s refusal to investigate individual complaints is an issue hundreds of families have raised with us.” 

A spokesperson for Hiqa said regulations require a registered provider to notify them of any serious injury to a resident that requires immediate medical treatment.

“It is important to note that not all falls result in serious injury,” they said, adding that providers are not required to notify the body of every fall that occurs. 

“Inspectors have a constant focus on key risks in nursing homes, such as falls," said the spokesperson.

“Even in the absence of any notifications about falls, inspectors will review care planning, healthcare, staffing levels, risk management, complaint management on the majority of inspections.” 

They added that a statutory investigation by the body "does not carry any enforceable sanctions" and as such, may not mean any improvements for a resident's care. 

Regina gets emotional when she looks back over the last few months of her beloved father’s life.

“I was my father’s main carer for many years before he eventually had to go into the nursing home.

“I bitterly regret that the one time I wasn't responsible for my father’s care, he ended up suffering the most harm.

I also regret the day my father crossed the threshold of that place.” 

Her voice struggling through tears, she added: “There is never a right time to lose a parent but I think to lose them under these circumstances is just so heartbreaking.

“We could have had him another month, maybe even another year if he hadn’t suffered so much in the end.”

Mr O'Sullivan had been a painter and decorator and worked in his family’s business, run by his father Jeremiah O'Sullivan.

Clients included Christ the King Church in Turner’s Cross, where his wife Eileen was an organist, and Kent Train station in Cork city.

The father-of-five also worked for a time as a maintenance worker at St Finbarr' Hospital.

A fan of the Lotto, he once won €3,500 but gave it to charity rather than keep it.

A keen snooker player and fan of the game, he got to meet many of his heroes in Cork when they played testimonials there, including Steve Davis, Alex Higgins and Dennis Taylor.

After he retired, one of the first things he did was restore the stations of the cross on display in the South Parish Church on Dunbar Street.

Up until the age of around 90, Mr O’Sullivan performed with his accordion at a variety of locations in Cork city, including Brother Jerome Kelly Day Care Centre at the back of Mercy Hospital, the Turner’s Cross Daycare Centre and Marymount Hospice.

Eileen died suddenly in July 2020, aged 89, by which time he had gone into the Bon Secours home.