Open verdict recorded after 95-year-old nursing home resident found dead with duvet over head
Bridhaven Nursing Home in Mallow, Co Cork, apologised for the failings identified in the care of Marcella O'Sullivan who was found dead in her bedroom at the home shortly after 8pm on April 13th, 2022.
An inquest in Mallow, Co Cork, on Wednesday heard from medical staff at the home that another patient, who also had severe dementia, was in the room when they entered at 8.03pm that night.
Coroner Frank O'Connell was told that the other woman was a 'roamer' who entered the rooms of other patients and picked up items. CCTV footage analysed by gardaí indicated that she went to Mrs O'Sullivan's room more than 100 times on the day she died. The vast majority of her visits lasted a few seconds.
The evidence was that the duvet was not over Mrs O'Sullivan's head when she was last seen by staff shortly after 5pm. Mr O'Connell said that it was accepted that Mrs O'Sullivan was physically unable to lift the duvet herself.
Assistant State Pathologist Margaret Bolster carried out a postmortem on the deceased. She said the case was complex.
Dr Bolster said it was her opinion, and those of her colleagues, that Mrs O'Sullivan died after her airways were covered by the duvet, leading to an aspiration of her gastric contents.
She said that there was a history of dysphagia (difficulty of swallowing) which meant that the pensioner was on a liquid diet. Dr Bolster noted that the duvet cover was 'less breathable' as it was waterproofed. She said that the deceased had a bruise on her tongue. There was also a large amount of vomit.
Mrs O'Sullivan had been fed by staff at about 5pm that day. She was comfortable, had her eyes open and the duvet was at her waist. She wasn't checked again by staff until 8.03pm when she was found dead.
A decision was made to contact gardaí arising from the circumstances in which Mrs O'Sullivan was found dead. A file was prepared for the Director of Public Prosecutions (DPP).
Det Insp John O'Connell said that the woman who was in the room when Mrs O'Sullivan was found dead was assessed by an expert geriatrician. He deemed her not capable of recalling the evening on which Mrs O'Sullivan died. This woman has also since died.
Det Insp O'Connell said the DPP directed that no criminal prosecution be made in the case.
He said they were left with two possible explanations.
The first scenario was that Mrs O'Sullivan vomited and died with the duvet then being placed over her head by the other patient. The second scenario involved the other dementia patient putting the duvet over Mrs O'Sullivan's head and her aspirating her gastric contents, and dying.
Det Insp O'Connell said that there was 'no clear evidence' forensic or otherwise to suggest that the other woman intended to cause harm to Mrs O'Sullivan. He said that the other woman 'had no history of aggression.'
The six person jury recorded an open verdict. The foreman said that they were all of the belief that a third party put the duvet over the head of Mrs O'Sullivan. However, they couldn't say who that person was or whether it occurred before or after she died.
Coroner Frank O'Connell offered his heartfelt condolences to the family of Mrs O'Sullivan whom he said had passed 'on to her reward'.
He thanked the O'Sullivan family for the enormous dignity they had shown during the inquest.
Barrister Christian Douglas, BL, apologised to the family of Mrs O'Sullivan on behalf of Bridhaven nursing home.
'Bridhaven nursing home wishes to express our deepest and most sincere apologies ...(for) the failings identified. We understand the pain and distress this has caused.'
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