A MEDICAL professor has told the trial relating to the death of Evelyn Joel that a community care plan should have been put into action by a multidisciplinary team to determine her needs.
Prof Patrick Carr said her case highlighted “cracks” in the health system.
Mrs Joel’s daughter Eleanor (37) and her partner and co-accused, Jonathan Costen (39), each face a charge of the unlawful killing of Mrs Joel (58) by neglect on January 7th, 2006, causing her to die of pneumonia and complicating sepsis syndrome due to infected pressure sores due to immobilisation, due in turn to multiple sclerosis, at their home in Cluain Dara, Co Wexford
Prof Carr said Mrs Joel had primary progressive multiple sclerosis, describing the illness as a “one-way street”.
The GP was the fulcrum of any multidisciplinary team – community nurses should be heavily involved and there would be close liaising between the GP and nurses, Prof Carr said.
The professor said an occupational therapist would be required to see what aids a patient such as Mrs Joel would need.
Prof Carr said Mrs Joel was doubly incontinent since 2000 and had pressure sores and health issues linked to her MS. A physical monthly check should have been carried out on her initially, and following this every three months, in relation to her incontinence.
He told the court no GP visited Mrs Joel following her discharge from hospital in 2000, adding the only support she had was from her daughter.
When asked by John O’Kelly SC, for Mr Costen, how difficult it would be for someone untrained in caring for a primary progressive MS patient, Prof Carr said it would be virtually impossible.
“Coping with double incontinence, pressure sores, behavioural problems – all these things are very difficult even for trained staff. For someone who has absolutely no training and given the lack of support that was forthcoming, the job was virtually impossible.”
Asked how a carer of an MS patient would cope if their condition went rapidly downhill, Prof Carr said the carer would be in an impossible position. Family members of patients should be involved in preparing care plans.
Prof Carr said people with progressive MS often could not think rationally. When Mr O’Kelly asked him whether there was anything in the records to indicate the possibility Mrs Joel refused help due to cognitive degeneration, he replied there was clear evidence she refused help and needed help.
Prof Carr said a proper assessment of her mental health capacity would have led to the conclusion she be referred to a consultant, adding there was no evidence this was even considered. There was a lack of communication between all the parties in the multidisciplinary team. “I got the clear impression that Mrs Joel was just simply falling through the cracks,” he added.
He said after Mrs Joel was discharged from the care of consultant neurologist Prof Michael Hutchinson, there was no evidence of any multidisciplinary help forthcoming.
Justin Dillon SC, for the State, said the willingness of the patient to engage with the multidisciplinary structure was essential so, following on from this, if Mrs Joel had said her wish was not to become involved, this had to be respected.
Prof Carr said Mrs Joel was “dead against” going back to hospital, having spent over four weeks at Wexford General in 2000.
Mr Dillon said the HSE did not have the power to force itself on a patient. Prof Carr replied Prof Hutchinson expected the HSE to provide care for Mrs Joel. “He wanted some sort of a multidisciplinary input into providing a care package for her.”
Mr Dillon said Mrs Joel’s former GP Dr William Lynch said the patient and the family needed to buy into the process. Prof Carr said the patient obviously did not want to buy into the process.
Mr Dillon said if a patient could not express her needs, her carers should do so.
Consulting clinical psychologist Brian Glanville said he interviewed Mrs Joel twice, in January and February 2008. He took a lengthy written history from her and administered some psychological tests.
Prof Glanville concluded she had grown up in extremely adverse circumstances in a dysfunctional family unit in which her father drank heavily. Prof Glanville said her education was at the lower end of the average range, adding she took on the role of homemaker at a young age.
Mrs Joel moved her daughter and son out of the family home on a number of occasions because of her husband’s drinking, and she eventually became involved in a relationship with his brother.
In late 2004 she moved in with her daughter and partner. Prof Glanville described this as an added care burden, adding Mrs Joel would not allow her daughter to wash her. The court heard that in the 14 months Mrs Joel lived at the house, she probably only had one bath.
The court also heard that nobody had asked Eleanor Joel whether she needed help caring for her mother, and that she did not have support from other family members.
Under cross-examination from Mr Dillon, Prof Glanville said Mrs Joel had been a dominant personality up until her health failed shortly before she died.
He said her resistance to help probably dominated her daughter’s thinking almost to the end of her life, adding she perceived there was professional help coming to her mother through public health nurses. The trial continues at Wexford Circuit Court.