Hospital and council respond to appeals by Mayo coroner

Both Mayo University Hospital (MUH) and Mayo County Council have responded to appeals made by the Coroner for the District of Mayo, Patrick O’Connor, last month at the conclusion of an inquest into the death of Patrick Rowland, Lahardane.

Mr. Rowland (69) fell into the Castlebar River and drowned after leaving MUH in the early hours of January 17, 2023.

After a lengthy hearing earlier this summer held in Swinford Courthouse, Coroner O’Connor returned a verdict of accidental death.

The medical cause of death was asphyxia due to drowning.

During the inquest, evidence was given that on January 15, 2023 Mr. Rowland, a father and grandfather, was admitted to MUH by ambulance and was afterwards diagnosed as suffering from pneumonia and sepsis.

He was put on a trolley in the emergency department and subsequently on a corridor in that area of the hospital for upwards of 42 hours.

Late on the night of January 16 he was transferred to a medical ward accompanied by medical staff and his son, Cormac.

At approximately 12.40 a.m., Cormac Rowland left his father in the ward and travelled home but at 1.13 a.m. he received a telephone call from his father that he was outside the hospital (in slippers and pyjamas) and wanted to be brought home.

When Cormac Rowland arrived in Castlebar there was no sign of his father and an extensive search was mounted which ended two days later when the body of the missing man was discovered downstream from Castlebar in the town river.

After delivering his verdict, Coroner O’Connor made a number of recommendations directed to Mayo University Hospital, Saolta and the HSE.

He recommended that MUH guidelines about sepsis and the recording of Early Warning Scores should be adhered to.

Also, the coroner advised that training should be given to all staff in the hospital on how to deal with patients who express a desire to self-discharge.

Coroner O’Connor also urged that guidelines be introduced in relation to “cues for caution” or steps thereafter with regard to monitoring patients to include the length of time on trolley, age and medical conditions.

He also urged that all relevant and clinical and non-clinical information regarding a patient should be recorded and given to the team at handover, especially at critical points particularly on the transfer from one unit to another in the hospital.

Acknowledging the issues raised by the coroner, Catherine Donohoe, Hospital Manager (MUH) informed him in a letter of response that she had reviewed the recommendations and “felt it important to give feedback.”

Ms. Donohoe said the hospital has guidelines in place as regards sepsis with assurance systems for compliance.

Her letter continued: “As a hospital we have one of the lowest ‘left before seen’ rates which we believe is due to our ability to respond and react to patients changing mood and intentions during their ED (emergency department) presentation."

She said there are national processes in place regarding the time and length of time for patients on trolleys.

Ms. Donohoe said there are also policies in place for the management of patients wanting to discharge against medical advice and the management of patients “who want to abscond from the site."

The coroner also made recommendations directed to Mayo County Council which has responsibility for roads, footpaths and amenities in the Castlebar area.

He called for the railing at the bridge where Patrick Rowland’s slipper was found to be fully examined and where necessary appropriate steps taken to have it identified with suitable warning signs.

He also requested that an appropriate barrier be placed closer to the town on the river so that if a person falls in the body won’t be carried outside the environs of the town.

Mr. Rowland’s body was found some two miles downstream of where he fell in.

Following the conclusion of the inquest Coroner O’Connor sent a copy of his recommendations to Kevin Kelly, chief executive of Mayo County Council.

In reply, Mr. Kelly has acknowledged the verdict of the inquest and the recommendations made.

He explained that he had referred the matter to John Condon, Director of Services, Castlebar Municipal District.

Coroner O’Connor has welcomed the fact that hospital management and Mayo County Council have acknowledged the verdict of the inquest and his recommendations.

He said: “Whilst this it is important that coroner’s recommendations are considered there is often no response from the parties to whom they are made and directed in many coronial districts in the country.

He continued: “In this case it is appropriate and interesting that the coroner’s recommendations have been not only acknowledged but also dealt with by the parties to whom they were addressed”.

Earlier this summer, members of Mr. Rowland’s family and other relatives packed into Swinford Courthouse for the conclusion of the lengthy inquest into the death of their loved one.

Afterwards, while welcoming recommendations from the coroner directed at Mayo University Hospital, they expressed dissatisfaction.

Mr. Roger Murray, solicitor and senior counsel, (Callan Tansey & Co) said the Rowland family are contemplating civil proceedings against the HSE in relation to all the circumstances relating to the death.

Mr. Murray said it was the family’s steadfast position that had clinical and non-clinical information been given to hospital staff at handover that Patrick would never have been next, nigh or near a river and the ‘calamity’ would not have happened.