DOCTORS AT a Dublin hospital did not identify fatal injuries sustained by a 104-year-old woman who fell at a nursing home when a hoist used to lift her failed.
Mary Tobin, care of Belvilla nursing home, South Circular Road, Dublin, broke three ribs and her left collarbone in the fall on January 24th, 2009.
The sling was not appropriately secured prior to operating the hoist, which was being used to lift the woman from her bed to a chair, an inquest at Dublin City Coroner’s Court heard yesterday.
Both of the lower straps (of the sling) were incorrectly attached to the hoist, and an inappropriate size of sling was used.
Ms Tobin fell between three to four feet, and was rushed by ambulance to the AE department of St James’s Hospital where she was examined, but the fatal injuries were not identified.
The 104-year-old woman, who had suffered a stroke in the past and was unable to talk, was treated for a head injury and had been cleared for discharge back to the nursing home when she collapsed and died suddenly in the AE department.
A postmortem found she died from a cardio-respiratory arrest, secondary blood loss secondary to multiple bone fractures.
Coroner Dr Brian Farrell said he would record a verdict of death by misadventure because of a number of risk factors.
They included the fact that the sling was not appropriately secured to a bar on the hoist; the inappropriate size of the sling used (medium was used rather than small, which was recommended in an individual assessment); the failure of the hoisting operation; the fact that the fatal injuries were not identified at the AE department and the age of the deceased.
He also raised the issue of communication between staff at the nursing home and staff at the hospital.
The court heard that on the morning of January 24th two nurses, Sheila Lawlor and Maureen Iboko, were moving Ms Tobin at the nursing home when one side of the hoist gave way. Just one nurse was standing beside the hoist at the time.
“We want to apologise to the family. We’ve taken every measure we can to prevent anything like this happening again,” said the director of nursing at the nursing home, Judy Vahey.
Ms Vahey said both nurses had undertaken manual handling training on two dates in 2008 and were familiar in the use of the particular hoist, which was used in the training course. However, they had not been trained specifically by her in its use. Since the incident members of staff are trained in the use of specific hoists and slings, the inquest heard.
AE consultant at St James’s Hospital, Patrick Plunkett, who did not see Ms Tobin on the day in question, said that upon arrival at the hospital a history was given that Ms Tobin had fallen from a hoist approximately two feet on to the ground, banging her head.
The lady was examined by a senior registrar, a laceration on the back of her head was sutured, and a CT scan of her brain was carried out which showed no injury.
Mr Plunkett said the focus was on a head injury and it was not on the possibility she might have rib fractures. It was unlikely that they could have prevented the death even if they had diagnosed the fractures and was prepared to say they “couldn’t have prevented it”.
He said it was a “sudden, unexpected death”, and the amount of bleeding from three fractured ribs and a fractured collarbone would not be expected to cause someone’s death.
“I think we’re dealing with very unusual circumstances. We very rarely get people of such an advanced age. It was an error in the attachment of the lower loops so it was human error,” said the coroner, who endorsed recommendations made in a HSE report with regard to training and other matters.
Counsel for the family, Eavanna Fitzgerald, said the family was not satisfied with the way elderly patients were treated at St James’s Hospital and would like to voice that.
The coroner said he would write to the hospital on the matter.