Family fights a long battle to get answers from State bodies over their sister’s death
Catherine Davis was in a bad way. The alcoholism that had dogged her adult life was at a critical stage. Her family decided to seek help.
On Thursday, June 14, 2007, Catherine’s brother Michael Farrell drove her to St Michael psychiatric unit in Clonmel, which is located on the grounds of South Tipperary General Hospital.
Nine years after that admission and all that followed, Catherine’s family are still seeking answers from State agencies they believe failed her. The case is currently being investigated by the Garda Ombudsman, on foot of direction from the independent review mechanism set up in 2014 to examine cases such as hers.
Catherine was 35, a separated mother of two daughters. She had battled alcoholism for many years and no longer had custody of her children.
It was late when she and her brother arrived at that hospital that night. Michael had to knock on the door. He was told that the unit no longer treated alcoholics, and Catherine would have to be admitted to South Tipp Gen.
She was seen at the hospital at ten to one in the morning. Her brother asked that he be contacted in the event of Catherine attempting to leave. The sheet documenting her admittance referenced the alcohol detox she was to receive: “Her brother is concerned and has requested that if pt [patient] decides to sign an AMA (release form Against Medical Advice) could he please be contacted first. He is only 15 mins away.”
Catherine was administered a number of drugs to help her detox and put on an intravenous drip.
Over the weekend, her family made several attempts to talk to her doctor but were told they would have to make an appointment.
On Monday, Catherine’s mother Christina made contact with the doctor’s secretary, who told her that she would be back on.
That evening, unbeknownst to her family, Catherine checked out of the hospital in the company of a man she had met there, Niall Costin. He had his own problems and there is no suggestion that he was responsible for what would unfold.
The following morning, Catherine was brought by ambulance to the hospital A&E department in an unconscious state.
She had collapsed at a clinic while waiting to meet a welfare officer about acquiring accommodation.
“Her condition was stable on arrival,” a subsequent HSE report stated. “Blood pressure was low but improved with intravenous fluids. Catherine was in no immediate danger, was alert and responding to staff so no urgency to contact family.”
She was on a trolley until 2.30pm that afternoon before a bed was found. She asked a nurse to ring her family, and her sister, Susan O’Mahoney, arrived within half an hour.
“I was immediately concerned with how unwell Catherine looked,” Susan says. “Nobody told me what had happened. I was so concerned I told Catherine I was going home but would be back later. She was happy with that, but both of us were crying, and Catherine said ‘don’t worry about me, everything will be alright’.”
That was the last time Susan saw her sister alive.
Just before 6pm, Niall Costin arrived at the hospital and said Catherine wanted to leave. Mr Costin himself was asked to leave but he didn’t. At 7.30pm, Catherine left with him, as a HSE report would find.
“At 19.30hrs, Ms Davis approached a staff nurse stating that she wished to discharge herself from the hospital, she was advised not to leave against medical advice but refused to stay and signed an Against Medical Advice form in the presence of Medical SHO.
“Ms Davis informed staff that she had contacted her sister and informed her she was leaving the hospital. She then left hospital with afore mentioned male friend, who was not an inpatient in South Tipperary General Hospital.
“Ms Davis did leave the hospital in night clothes but refused to stay any longer.”
Susan and her father arrived at 7.40pm, 10 minutes after Catherine had checked herself out. They had not been alerted that she had left and, after failing to locate her in the ward, they inquired as to whether she had been returned to A&E.
They attempted to glean some information about Catherine’s departure, but were told that staff were bound by patient confidentiality. All they could say was that Mr Costin was from the Clonmel area. All they knew was that she had left without clothes, money, or phone.
In fact, Niall Costin and Catherine Davis had left with Costin’s, niece, Edel O’Dwyer, who had received a call from her uncle asking to be picked up at the hospital.
Ms O’Dwyer later told an inquest that she was concerned for the woman, who was dressed in a hospital gown, and was uncomfortable transporting them. The woman said she wanted to leave, and Mr Costin reassured his niece.
“I said to Niall I don’t want to bring her away from the hospital and he said it was OK, she is coming back to my home,” says Ms O’Dwyer. “He said he would give her a tracksuit and jumper. I brought them to his house.”
After arriving at Mr Costin’s house, the pair drank whiskey, cider, and beer. They kept drinking the next day. The next day, Mr Costin woke at 7.30am and left soon after to visit family in Waterford. When he returned, he couldn’t wake Catherine and she felt cold.
The emergency services arrived at 3.11pm and found Catherine on the couch in the sitting room. They could find no signs of life.
Meanwhile, Catherine’s family was growing frantic. Michael contacted a garda friend in the station in Cahir. He in turn put a call into Clonmel and passed on what he knew of Mr Costin, and said the family was extremely worried. Yet, little was done.
It emerged during the inquest that no record was kept in the Clonmel station of the call. Nobody checked Pulse to obtain Mr Costin’s address, even though he was known to officers through a history of petty offences. Nobody thought it necessary to visit the address where this vulnerable woman, whose family were distressed about her whereabouts, might be. Nobody did anything, really.
Catherine’s family believe if action had been taken, the outcome may have been different.
The family feels they and Catherine have been badly let down by both the medical services and An Garda Siochana. The family had not been contacted, as requested, in the event of Catherine leaving the hospital.
When her sister and father arrived 10 minutes after her departure they had not been told of Mr Costin’s address. This information was available in the hospital as he had recently been a patient there.
The inquest heard gardaí had made no effort to locate her despite being alerted that she was highly vulnerable and in the company of a man with his own history of alcohol abuse.
The HSE put together a report on the case within six weeks of Catherine’’s death. Shortcomings were identified. At the inquest in July 2008, coroner Paul Morris pointed to a culture within the HSE that still rings true today.
He said that if somebody was at considerable risk or incapable of protecting themselves, the policy of right to privacy should be overridden.
“There seems to be a culture, and I may be unfair in this, that no one makes a decision because they are afraid of being made accountable,” he said.
“There should be a situation where a person should not be criticised if they made a judgement call and release the information on the grounds that somebody is at risk.”
Catherine’s death was investigated by the gardaí, but once it quickly became obvious that there were no suspicious circumstances involved, there appears to have been little effort to determine the full facts.
No attempt was made to discover why no action was taken, particularly in Clonmel, once officers were furnished with the facts.
There was also a failure to gather all relevant statements from those who had interacted with Catherine in South Tipperary General Hospital.
Susan says her brothers were asked by a senior garda not to speak to reporters about the case.
An official from the Department of Justice recently wrote to Susan in relation to findings of the Independent Review Mechanism, set up to examine more than 200 complaints relating to the force: “You appear to have been poorly treated by a sequence of gardaí who failed to deliver on their promises of giving statements from medical personnel and you appear to have been subjected to unfair and rude treatment.”
The family pursued a complaint with GSOC but that body found that there had been no breach of discipline.
The counsel who examined the case for the independent review mechanism found this outcome “curious” and went on to “point out that the finding appears to have been arrived at as GSOC was unable to bring about a finding of breach of discipline purely for the fact that no garda would come forward and indicate that it was he or she who had failed to log the call in respect of Cahir Garda Station, nor did any garda admit to having received a call at Clonmel and being guilty of a failure there”.
The outcome from the Independent Review Mechanism was that GSOC should re-investigate the case.
The result has brought some comfort to Catherine’s family, who had felt that the circumstances leading up to her death had been brushed aside.
Susan suffered acutely from the bereavement and a deep sense of injustice in the wake of her sister’s death.
“At the time when it’s happening you feel so alone,” she says. “And then years later all these other cases come out and you get a sense of relief that you’re not mad yourself.
“I come from a small village and at the time I was diagnosed with severe traumatic stress from it all, and then when I found out what was happening with the gardaí, I became very angry.”
The Irish Examiner understands that GSOC is now at an advanced stage in its reinvestigation of the family’s complaint.
But it’s been a long haul to get some closure, nine years on from a tragic loss.
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