Paul Gogarty (Dublin Mid West, Green Party)
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I thank the Ceann Comhairle for giving me the opportunity to raise this matter with the Tánaiste via the Minister of State. Rita Nolan was a normal young woman who fell ill shortly after marrying her husband John. The personality disorder from which she suffered made her life difficult. As her condition deteriorated she became an increasing danger to herself and others, and she had to be hospitalised on a semi-permanent basis. This situation was obviously stressful for Rita and her family. That she was an intelligent woman who was lucid for much of the time made her experience even more upsetting and placed an enormous burden on her husband John and their two young sons.

This stress was nothing, however, compared to the shock and upset caused by Rita's untimely death in St. Brendan's Hospital last year. Rita Nolan died from an infection in her oesophagus caused by having swallowed the broken top of a coat-hanger two days previously. An inquest into the circumstances surrounding her tragic passing recorded a verdict by misadventure. Although my medical knowledge is limited, I understand that this term is used to describe a situation where the full facts cannot be ascertained, such as verdicts concerning drowning, vomit inhalation, alcohol poisoning and other deaths whose causes are inconclusive. Rita Nolan's case warrants further investigation. Under the Coroners Act 1962, the coroner has the right to summon a medical practitioner to attend an inquest. However, he cannot summon a second doctor unless expressly requested by a majority of a jury, if they are not satisfied with the cause of death. One doctor can explain the cause of death, but it takes all doctors involved to provide a full picture of the circumstances surrounding a death. The two other doctors involved in monitoring Rita did not turn up. Instead, the hospital stuck to the letter of the law and brought its solicitor along to cover its backside.

We are still awaiting the introduction of the new Coroners Bill, which will provide for increased sanctions for people who refuse to co-operate with the proper conduct of an inquest and will end the restriction on the number of medical and other witnesses that can be called. I await this with great eagerness.

In Rita's case and under the existing legislation, only one doctor could be called. In this case the doctor on duty on Thursday, 8 April testified that after Rita broke the piece of a coat hanger and swallowed it, he got a torch and a pair of gloves and removed the item. He asked how she was and she replied fine. The next day she complained of throat pain and was administered Panadol by another doctor. No other examination seems to have taken place.

This was Friday, 9 April. The next day she became increasingly distressed and was administered antibiotics by yet another doctor. She died at 6 p.m. on Saturday evening. The abscess on her throat caused her to choke to death. The autopsy simply stated that a foreign object punctured her oesophagus and it got infected. However, this does not tell the whole story. The coroner was as critical of the hospital in his report as he could be. He was so critical that we need to find out more.

What needs to be investigated is the information passed between consultants and the procedures and practices in operation at St. Brendan's. Given that Rita had been involved in previous swallowing incidents, including a situation where she swallowed a spoon, which required removal by surgery in a general hospital, would it not have made sense, for example, for a note to be left from one doctor to another. No-one knows if such a note exists, at least nobody concerned with the inquest. Why, for example, was a follow-up X-ray not carried out, given Rita's case history? Her family believes that she would still be alive today if an X-ray had been taken.

Were any special monitoring instructions given in Rita's case? What exactly happened in terms of follow-up? If someone swallowed a coat hanger, surely some follow-up was needed. Where were the checks and balances? As it was a psychiatric doctor who attended her, what basic medical training did he and others dealing with her have?

It could well be that nothing untoward happened and that every procedure was carried out properly, or it could be that an unfortunate overworked member or members of staff, or the policy makers in hospital management, are collectively guilty of negligence leading to Rita's death. The family only wants the truth, but the information provided by St. Brendan's has been sparse to date. Only give out what you must seems to be the message that went out. The first time the family had any personal contact from St. Brendan's was a mumbled condolence at the inquest. The family seeks the truth and deserves better.

Both Rita's family and I as a public representative have nothing but the highest regard for staff in St. Brendan's and all health care staff who work long and dedicated hours in sometimes trying conditions within our creaking health care service. However, we want the truth. What exactly happened? Was it in line with normal practice and was normal practice good enough? Rita has moved on, but her family cannot move on until all the facts of this case are revealed. I urge the Minister of State and the Tánaiste to use their good offices and order a full investigation into all the facts surrounding Rita Nolan's untimely death.

Tim O'Malley (Limerick East, Progressive Democrats)
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I thank Deputy Gogarty for raising this matter on the Adjournment. The case to which the Deputy referred is a tragic one and I extend my condolences to the family concerned. Every death of a patient 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 St. Brendan's Hospital submitted a report on the circumstances surrounding the death to which Deputy Gogarty referred to the inspector of mental health services. In May 2004 the Mental Health Commission considered this report, dated 27 April 2004. The commission informed my Department that it intends to review the circumstances of this death now that the inquest has been completed.

The Mental Health Commission is an independent statutory body established under the provisions of the Mental Health Act 2001. 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. Towards this end, the commission is currently developing a quality framework for the delivery of our mental health services. 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.

Paul Gogarty (Dublin Mid West, Green Party)
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Will the Minister indicate the timeframe for such a review and when a report will be made available?

Tim O'Malley (Limerick East, Progressive Democrats)
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The inspector and the commission will analyse the case. There is no timeframe, but they will do it quickly. As the Deputy is aware, the statutory inspector appointed by the Mental Health Commission, Dr. Teresa Carey, will put her first report before the Oireachtas shortly, probably before the end of this month. Whether she will report on this death is up to her. She is independent and I will receive the report the same time as it is laid before the House. I presume she will inspect this case quickly as possible. I will relay the Deputy's concerns about this case to her.