Since his wife Nuala lost her life three years ago after a brain haemorrhage, Jim Lawless has been on a quest to get answers about how and why she died. This is his story as told to FIONA TYRRELL
JUST NINE days after celebrating her 49th birthday in late December 2004 my wife Nuala collapsed at home. Our eldest son Jim immediately began to resuscitate her on the kitchen floor.
Although she had stopped breathing, Nuala had a strong pulse. Jim applied mouth-to-mouth resuscitation for 20-25 minutes, as we awaited the arrival of the Dublin Fire Brigade ambulance.
On arrival in A&E in Tallaght Hospital we were quickly informed that Nuala had probably suffered a subarachnoid haemorrhage. Tests and a CT scan confirmed this diagnosis. Nuala remained unconscious.
The prognosis was grim, but we felt that where there is life there is hope, and so began a very long journey into the unknown.
Tallaght Hospital is not equipped to treat brain trauma. The national neurosurgical centre in Beaumont Hospital is where expertise is concentrated. As I understand it a patient that has suffered an aneurysmal subarachnoid haemorrhage has a high risk of suffering a second haemorrhage within 14 days unless the ruptured aneurysm is secured.
Over the Christmas period Tallaght Hospital contacted the neurosurgical centre in Beaumont on several occasions, but requests for Nuala to be transferred for treatment were refused, even though she was scoring high on the Glasgow Coma Scale (a scale to measure the level of consciousness in brain trauma patients).
On January 3rd, 12 days after she was admitted, Nuala confounded the pessimists and regained consciousness. That morning there was an atmosphere of joy and jubilation as I walked into the intensive care unit. I think the nurses were almost as happy as we were.
Nuala was sitting out of bed, looking around inquisitively. She had a tracheostomy in situ and though she could not speak her smile said everything.
She smiled when the nurse suggested that they might put a gin and tonic into the intravenous drip. As our 12-year-son – our youngest – approached his mother, her eyes opened widely with delight.
Her improvement carried into the following day. Having regained consciousness we found it difficult to understand why Nuala was not being transferred to Beaumont for urgent treatment.
On the night of January 8th, I was called to Tallaght Hospital. Nuala was having a second haemorrhage. It was the most horrific experience imaginable. She was in a lot of distress. With each spasm I knew that hope of recovery was ebbing away. I cursed Beaumont.
Very quickly my faith in the medical profession was restored. A young doctor (a registrar in neurology) took control. He contacted Beaumont Hospital and made such a passionate appeal for help that Beaumont accepted my wife for treatment. She was now unconscious.
At Beaumont, a drain was inserted to reduce the pressure on Nuala’s brain and a coil was inserted to secure the ruptured aneurysm. While her condition stabilised her level of consciousness did not improve.
It must be said that from the moment Nuala was admitted to Beaumont the treatment and care she received was outstanding. No stone was left unturned to ensure that she had the best possible chance of recovery.
For the next three months, Nuala fought off various infections. When they had cleared, she was referred back to Tallaght, where it was felt her rehabilitation could be best managed.
It was as difficult getting Nuala back to Tallaght as it was getting her into Beaumont in the first place. There were no beds at Tallaght thanks to a recent outbreak of winter vomiting bug. After a month’s wait and following a meeting with the bed manager in Beaumont an exchange of patients occurred and Nuala was moved to Tallaght Hospital.
Tallaght does not have a high dependency unit and we were relying on regular ward nursing, which understandably could not compare. As Nuala’s recuperation continued, so did the plague of infection. Nuala went on to suffer a third haemorrhage, and died on June 18th, 2005.
In the aftermath of this tragedy, my quest to find answers has been frustrating. Beaumont Hospital in particular has been less than helpful.
A report from Prof J P Phillips in Beaumont Hospital states that Nuala was initially deemed too ill for surgical treatment. However, when she stabilised on January 3rd, had a tracheostomy in place and her Glasgow coma scale began to improve “she was then suitable for early elective transfer to Beaumont Hospital”, he wrote.
Despite this, it was not until a second haemorrhage that Nuala was accepted for treatment in Beaumont – five days later. My research indicates that there were several beds available in Beaumont during that period. The problem is, I believe, that there is no protocol governing patient transfers from acute hospitals to the neurosurgical centre at Beaumont.
I have met Prof Ciaran Bolger from the department of neurosurgery in Beaumont and with Jon Billings, director of healthcare, quality and safety with HIQA. These meetings have been disappointing.
To my mind, the offer of treatment at Beaumont is very much a lottery and is dependent on which consultant neurosurgeon is on call. I feel there is no transparency and, in the absence of a standard, no consistency when it comes to deciding which patients will be accepted for treatment.
A report written by Dr Paul Crowley, a consultant neurologist who attended my wife in Tallaght Hospital, said her case “highlights the difficult position encountered by all hospitals attempting to refer patients to the Beaumont neurosurgical unit”.
“There is an inconsistency in their patient selection. They often decline to take a patient in the early stages, only to accept them later,” he said.
I believe that the “warehousing” of critically ill brain trauma patients in admitting hospitals, while they await clearance for admission to Beaumont, is unacceptable.
It has to be said that Nuala’s treatment in Tallaght Hospital was not flawless either. But the hospital took on board most of my concerns and in early 2006 undertook a programme of retraining general nursing staff in the management of patients with tracheostomies. I believe that there has been a significant reduction of deaths in tracheostomy patients since.
Under the Freedom of Information Act, and after much resistance from Beaumont, I obtained a copy of Safe Neurosurgery in Ireland 2006, a summary of Beaumont's request for funding to the HSE.
This report states that a minimum of 11 neurosurgeons is required to realise safe neurosurgery practice in Beaumont. The report also notes that that the hospital is in breach of core guidelines from the Society of British Neurological Surgeons regarding safe neurosurgery practice.
Twenty years ago there were six consultant neurosurgeons in Beaumont Hospital, today there are seven and one paediatric neurosurgeon. While funding is vital, leadership is just as important. I believe that if neurosurgical service had strong leadership, neurosurgery would be better.
Against all the odds, having survived all that life threw at her – two brain haemorrhages, a heart attack, hospital-acquired MRSA, VRE and pneumonia – I think Nuala could have survived with the right help.
After waking from a coma I believe that all that stood in her way was a pile of paper, inefficient management and a web of inconsistency.
Three years later questions concerning her death still remain unanswered.
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In response: protocols, standards, improvements and investments
In a statement issued to
The Irish TimesBeaumont Hospital said it is "satisfied that appropriate protocols were in place then, as now, and that they were adhered to, as was best practice with regard to judgments on the transfer of his wife taking all relevant clinical factors into account".
"Contrary to Mr Lawless's assertion, bed availability was not a relevant factor in this," the spokesman stated, and there were many clinical factors involved.
"While a range of protocols exist with regard to administration and decision making on inter-hospital transfers, it should be noted that these are continually audited for effectiveness. Improvements are made on an ongoing basis, Beaumont continues to work closely with HIQA on this."
Finally, the hospital states that since 2006 there have been "significant investments" in neurosurgical services in Beaumont: "These include the appointment of an eighth consultant neuro- surgeon, an additional consultant anaesthetist and specialist registrar, clinical specialist physiotherapist, three specialist nursing posts and a number of support staff."
In a statement the Health Information and Quality Authority (HIQA) said its priority is to "develop generic standards to drive improvement in quality and safety across the whole health system", but confirmed that "a specific standard covering the transfer of cranial haemorrhage patients is not in our immediate plans.
"However, we will continue to engage with those planning, funding and providing services to ensure opportunities to improve safety for such patients are identified and implemented." A Tallaght Hospital spokeswoman stated that a nurse-training programme in the management of tracheostomy patients has been put in place in the hospital.