News
Woman died in hospital after alarm not heard
Staff caring for an 80 years old woman failed to hear a warning alarm alerting them to the fact that she had become disconnected from a breathing ventilator, an Inquest into her death heard.
On account of this being the second such incident in the critical care units of UHG, Coroner for West Galway, Dr Ciaran MacLoughlin, recommended that the HSE would issue a statement to assure members of the public that a review had taken place following this incident, and that ICU/HDU were safer places to be as a result.
Neither the nursing staff, nor the doctors doing their rounds at the time, heard the beeping noise to indicate that the life of Ann Downes, of 12 Bayview Heights, Ballybane, was in danger.
“This is the second occasion that this has happened (March 2012),” the Coroner pointed out to witnesses and family members.
“I was given to understand that corrective measure were put in place to ensure that this would never happen again. It is in the general public’s interest what happened, and why measures don’t seem to be in place.
“When it comes to the equipment, it doesn’t matter how ill the patient is, all must be treated the same. I know Mrs Downes was a very ill person, and that death was expected, but it is not reasonable to say that when the respirator malfunctioned no one knew.”
William Downes assumed his mother was asleep when he visited her on the afternoon of November 18 last year. He said that for about 30 minutes, no one came near her, until a male staff member called out her name. When he got no response from her, he became concerned, and Mr Downes was ushered out.
His mother, who had been admitted nearly a month earlier with hip and knee pain, was pronounced dead at 2.35pm.
An infection in her prosthetic knee had caused multi-organ failure, and she was unexpected to make a full recovery, but her medical team had hoped that she would be able to go home.
When her ability to breathe independently improved, she was moved from ICU (Intensive Care Unit) to HDU (High Dependency Unit), where the ratio of staff-patients is 1 to 2. There she was receiving a small level of ventilation support.
Consultant anesthetist, Mr Patrick Nelligan, saw her several times on the morning of November 18, and again at 1.30pm. He said that a team of doctors were doing their medical rounds at 2.15pm, but avoided Mrs Downes as she was being dealt with by the infectious diseases team, and the curtains were pulled around her bed space.
Nobody heard the alarm going off, until the nurse in charge, Sean O’Shaughnessy, was returning to the nurses station and noticed the beep – a recording of the same alarm was played for the Coroner, after which he noted: “It doesn’t seem to inspire any degree of urgency … you would be oblivious to it.”
When asked by the Coroner if Mr Downes – who was not present at the hearing – had heard the alarm, the nurse said: “he brought no attention to us at that time… there was nothing significant that said to me ‘stop what you’re doing, someone is in critical difficulty.’”
Assistant Director of Nursing, Catherine Lee, said the HDU unit was a very busy and often noisy ward, with telephones, equipment, and talking, combining to create “a cacophony of noise.”
When asked what measures had been implemented since Mrs Downes’ death, she said that the alarm settings were changed from default to being set according to the needs of the patient.
She said that the hospital’s response was to reduce unnecessary alarms, in order to make staff more aware of the important ones.
“We have reduced the alarms from 30,000 to 8,000 per week between ICU and HDU,” she said.
“There could often be nuisance alarms, such as if a patient coughs.”
However, Dr MacLoughlin was not satisfied. “You can make all the excuses – but why didn’t you see it or hear it,” the Coroner responded.
“This is in the public interest… I know you say that it’s a safe place to be, but was it safe on that day?
“It took 23 minutes before attention was drawn to this patient’s condition, by which time she was dead… The patient was in serious danger, and her condition should have been made known to staff immediately, irrespective of what was being done on the ward. There was a ward round going on at the time, there were numerous doctors around – there is something not right with that.”
Dr MacLoughlin returned a verdict in accordance with the medical evidence, that death was caused by respiratory failure due to bilateral bronchopneumonia.
“While I am aware that an internal review took place, this is the second occasion in which a ventilator was disconnected, and an internal review took place then also,” he said.
Significant state investment is required to address ‘shocking’ inequalities that leave cancer patients in the West at greater risk of succumbing to the disease.
A meeting of Regional Health Forum West heard that survival rates for breast, lung and colorectal cancers than the national average, and with the most deprived quintile of the population, the West’s residents faced poorer outcomes from a cancer diagnosis.
For breast cancer patients, the five-year survival rate was 80% in the West versus 85% nationally; for lung cancer patients it was 16.7% in the west against a 19.5% national survival rate; and in the West’s colorectal cancer patients, there was a 62.6% survival rate where the national average was 63.1%.
These startling statistics were provided in answer to a question from Ballinasloe-based Cllr Evelyn Parsons (Ind) who said it was yet another reminder that cancer treatment infrastructure in the West was in dire need of improvement.
“The situation is pretty stark. In the Western Regional Health Forum area, we have the highest incidence of deprivation and the highest health inequalities because of that – we have the highest incidences of cancer nationally because of that,” said Cllr Parsons, who is also a general practitioner.
In details provided by CEO of Saolta Health Care Group, which operates Galway’s hospitals, it was stated that a number of factors were impacting on patient outcomes.
Get the full story in this week’s Connacht Tribune, on sale in shops now, or you can download the digital edition from www.connachttribune.ie. You can also download our Connacht Tribune App from Apple’s App Store or get the Android Version from Google Play.
On the eve of completing his 150th marathon, an odyssey that has taken him across 53 countries, Loughrea’s Marathon Man has announced that he is planning to hang up his running shoes.
But not before Jarlath Fitzgerald completes another ten races, making it 160 marathons on the occasion of his 60th birthday.
“I want to draw the line in 2026. I turn 57 in October and when I reach 60 it’s the finishing line. The longer races are taking it out of me. I did 20 miles there two weeks ago and didn’t feel good. It’s getting harder,” he reveals.
“I’ve arthritis in both hips and there’s wear and tear in the knees.”
We speak as he is about to head out for a run before his shift in Supervalu Loughrea. Despite his physical complaints, he still clocks up 30 miles every second week and generally runs four days a week.
Jarlath receives injections to his left hip to keep the pain at bay while running on the road.
To give his joints a break, during the winter he runs cross country and often does a five-mile trek around Kylebrack Wood.
He is planning on running his 150th marathon in Cork on June 4, where a group of 20 made up of work colleagues, friends and running mates from Loughrea Athletics Club will join him.
Some are doing the 10k, others are doing the half marathon, but all will be there on the finishing line to cheer him on in the phenomenal achievement.
Get the full story in this week’s Connacht Tribune, on sale in shops now, or you can download the digital edition from www.connachttribune.ie. You can also download our Connacht Tribune App from Apple’s App Store or get the Android Version from Google Play.
From the Galway City Tribune – An impassioned plea for a ‘masterplan’ that would guide Galway City into the future has been made in the Dáil. Galway West TD Catherine Connolly stated this week that there needed to be an all-inclusive approach with “vision and leadership” in order to build a sustainable city.
Deputy Connolly spoke at length at the crisis surrounding traffic and housing in Galway city and said that not all of the blame could be laid at the door of the local authority.
She said that her preference would be the provision of light rail as the main form of public transport, but that this would have to be driven by the government.
“I sat on the local council for 17 years and despaired at all of the solutions going down one road, metaphorically and literally. In 2005 we put Park & Ride into the development plan, but that has not been rolled out. A 2016 transport strategy was outdated at the time and still has not been updated.
“Due to the housing crisis in the city, a task force was set up in 2019. Not a single report or analysis has been published on the cause of the crisis,” added Deputy Connolly.
She then referred to a report from the Land Development Agency (LDA) that identified lands suitable for the provision of housing. But she said that two-thirds of these had significant problems and a large portion was in Merlin Park University Hospital which, she said, would never have housing built on it.
In response, Minister Simon Harris spoke of the continuing job investment in the city and also in higher education, which is his portfolio.
But turning his attention to traffic congestion, he accepted that there were “real issues” when it came to transport, mobility and accessibility around Galway.
“We share the view that we need a Park & Ride facility and I understand there are also Bus Connects plans.
“I also suggest that the City Council reflect on her comments. I am proud to be in a Government that is providing unparalleled levels of investment to local authorities and unparalleled opportunities for local authorities to draw down,” he said.
Then Minister Harris referred to the controversial Galway City Outer Ring Road which he said was “struck down by An Bord Pleanála”, despite a lot of energy having been put into that project.
However, Deputy Connolly picked up on this and pointed out that An Bord Pleanála did not say ‘No’ to the ring road.
“The High Court said ‘No’ to the ring road because An Bord Pleanála acknowledged it failed utterly to consider climate change and our climate change obligations.
“That tells us something about An Bord Pleanála and the management that submitted such a plan.”
In the end, Minister Harris agreed that there needed to be a masterplan for Galway City.
“I suggest it is for the local authority to come up with a vision and then work with the Government to try to fund and implement that.”
Families queue up for school’s offer of free house
West has lower cancer survival rates than rest
Galway minors continue to lay waste to all opponents
Gardaí and IFA issue a joint appeal on summer road safety
Marathon Man plans to call a halt – but not before he hits 160 races
