Resident's death at nursing home remains undetermined following discovery of elderly individual covered by a duvet
In a heartbreaking turn of events, the family of 95-year-old Marcella O'Sullivan, a resident at Bridhaven Nursing Home in Mallow, Co Cork, received the devastating news of her death on April 13th, 2022, shortly after 8pm. Marcella, who was suffering from advanced dementia and physical limitations, was found in her bed with a duvet over her head.
Coroner Frank O'Connell offered his sincere condolences to the family of Mrs O'Sullivan, and Det Insp John O'Connell launched an investigation into the circumstances surrounding her death. The Assistant State Pathologist, Margaret Bolster, performed a postmortem on Marcella and determined that she died due to aspiration of vomit, with her airways covered by the duvet.
Marcella had a history of dysphagia (difficulty swallowing) and was on a liquid diet. The common causes for a nursing home resident dying from aspiration of vomit include impaired swallowing, decreased level of consciousness, neurological diseases, and a weakened cough reflex. These factors can lead to aspiration pneumonia, where vomit or other material is inhaled into the lungs, causing infection and inflammation.
Preventive measures to combat aspiration pneumonia include regular swallowing assessments and management, positioning during and after feeding, maintaining good oral hygiene and respiratory care, vaccinations, monitoring and staff education, and managing underlying conditions.
Det Insp O'Connell stated that there was no clear forensic or otherwise evidence to suggest that the other dementia patient in the room with Marcella at the time of her death intended to cause harm. The patient, who was a "roamer" who entered the rooms of other patients and picked up items, had no history of aggression.
The six-person jury recorded an open verdict, indicating they could not determine who put the duvet over Mrs O'Sullivan's head or whether it happened before or after her death. CCTV footage showed that the patient who was in Marcella's room visited her room more than 100 times on the day she died. The duvet cover used was waterproofed, making it less breathable, and Marcella also had a bruise on her tongue and a large amount of vomit.
Barrister Christian Douglas, BL, apologized to the family of Mrs O'Sullivan on behalf of Bridhaven nursing home for the identified failings and the resulting pain and distress. The nursing home has since implemented new measures to ensure the safety and wellbeing of its residents.
The DPP directed that no criminal prosecution be made in the case. The investigation concluded that the tragic death of Marcella O'Sullivan was likely an unfortunate accident, with two possible explanations: one where the other patient placed the duvet over her head after she vomited and died, and another where the patient put the duvet over her head and she aspirated her gastric contents, leading to her death.
In memory of Marcella O'Sullivan, her family and friends are calling for improved care and safety measures in nursing homes to prevent similar tragedies from happening in the future. Bridhaven Nursing Home has expressed its commitment to learning from this incident and working towards providing the best possible care for its residents.
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