Thursday, 16 June 2005
I thank the Ceann Comhairle for providing me with this opportunity to raise the issue of the death of Ms Anne Carroll, who took her life in an occupied and staffed six-bed psychiatric ward at Cork University Hospital on Sunday, 17 October 2004. I wish to express my sympathy to the members of Anne Carroll's family and to empathise with them in their sad and traumatic bereavement.
From her late teens until her death, she suffered from depression and anxiety. However, despite her illness, Anne was a happy and fun-loving person, who took a keen interest in history and horticulture. Her greatest interest was in her family, the home farm, but most of all in her mother who suffered ill-health and for whom she tenderly cared.
On 29 August 2004, Anne took an overdose and remained in a coma and on life support for four days in the intensive care unit of Cork University Hospital. Thanks to the dedicated medical care of the staff in the intensive care unit at CUH, she regained consciousness and was subsequently rehabilitated in a medical ward at the hospital. On 6 September 2004, she was transferred to ward GF in the acute psychiatric unit at Cork University Hospital. She remained a registered patient in the GF psychiatric ward at Cork University Hospital until her death on 17 October 2004. Throughout this time, she remained in an extremely depressed and anxious state, but had the support of her family at all times.
From 6 September to 17 October 2004, the family forcefully expressed its concern at Anne's condition to the staff of the GF psychiatric ward at Cork University Hospital. However the staff did not concur with the family's assessment. On 15 October 2004, she was deemed to be fit enough for discharge on a weekend home break, to return on Monday, 18 October with a view to being discharged. The family spent long hours during Friday night and Saturday of this weekend break reassuring her of its support and helping her out due to her severely depressed and anxious state.
On Sunday, 17 October 2004 Anne was found by her brother, at home, attempting to stab her chest with a knife and subsequently, while he telephoned her sister, she cut her wrist with razor blades. The family immediately rang the GF psychiatric ward at Cork University Hospital to advise the staff of the situation and to state that Anne was being returned to their care immediately. At 2 p.m. on Sunday, 17 October Anne was presented for readmission to the staff of GF Ward in the hospital, even though she was a registered patient on weekend release. She was first seen by a nurse and openly admitted that she had tried to stab herself and cut her wrists, as all she wanted to do was die. A full 90 minutes after arriving at the ward the doctor on duty eventually saw her. Throughout the waiting time of 90 minutes, she was extremely agitated and distressed and continually asked the nurses on duty if a bed was available for her. During her consultation with the doctor on duty, she was in a serious state of agitation, crying and telling him that she simply wished to die. After this consultation, the family outlined the events leading up to her readmission to the doctor and stated clearly that she was a serious danger to herself. The inability of any member of staff in the ward to confirm that she was to be readmitted was of extreme concern to her family and contributed, in the family's opinion, to her becoming more agitated.
At 4 p.m. the family decided that it was obliged to take action and made the decision to leave Anne at the hospital and return home. This course of action was taken to force the staff of the ward to look after Anne who was extremely ill and a great danger to herself. At 9 p.m. on Sunday, 17 October, a telephone call was received from the GF ward at the hospital, requesting the presence of members of the family. On arrival they were informed of Anne's death. Anne was last seen alive at 7.35 p.m. by nurses in the office. She had gone to the office looking for something or other but was told to return to her ward and that a nurse in the next shift would look after her. At 8 p.m. Anne was found dead, having taken her life by hanging herself from the rail bar in her wardrobe in an occupied and staffed six-bed psychiatric ward at Cork University Hospital.
In the opinion of Anne's family and me, this death was totally avoidable. She was taken into the GF ward in the hospital, having attempted suicide at home that day on two occasions. She had a very serious psychiatric condition and was crying out for professional care.
She should have been on 24 hour suicide watch and such treatment would have been the proper approach to her condition. The family entrusted the care of its sister to the Southern Health Board and is extremely upset at the situation. I appreciate that anything that can be done will not return Anne Carroll to her family. However, my desire and that of her family is to ensure that no other family can be exposed to this situation. We ask for an inquiry independent of the Southern Health Board to examine the facts of the case.
Brian Lenihan Jnr (Minister of State, Department of Education and Science; Minister of State, Department of Justice, Equality and Law Reform; Minister of State, Department of Health and Children; Dublin West, Fianna Fail)
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I thank Deputy Neville for raising this matter on the adjournment this afternoon. The case to which the Deputy referred is a tragic one and I extend my condolences to the family concerned. Every sudden death, from whatever cause, of a patient in psychiatric care is most regrettable. It would be inappropriate for me to comment in detail on any individual case. However, I am aware that in line with standard practice, the clinical director of the South Lee Mental Health Service submitted a report on the circumstances surrounding the death to which Deputy Neville referred to the Inspector of Mental Health Services.
Upon receipt of correspondence from a relative of the deceased in March 2005, my colleague the Minister of State at the Department of Health and Children, Deputy Tim O'MaIley, sought a report in the matter from the Mental Health Commission. One of the statutory functions of the commission is to promote and foster high standards and good practices in the delivery of mental health services.
On 9 May, the Mental Health Commission informed the Department that it was seeking further information regarding this case from the southern area of the Health Service Executive. The commission has since confirmed that it has received the additional information requested and that it expects to be in a position to provide a report to the Minister of State at the Department of Health and Children, Deputy Tim O'MaIley, in the near future.
As Deputy Neville is aware, the Minister of State has already indicated that he has decided to await completion of the final report of the Mental Health Commission before considering what further action may be required.
The Mental Health Commission has indicated that should recommendations arise which are applicable to all mental health service providers, they will be incorporated into the quality framework currently being developed by the commission. This framework includes the development of standards for mental health care, clinical governance and codes of practice. The inspections by the inspectorate of mental health services provide for the ongoing monitoring of such policies and standards by the Mental Health Commission.