Hospital inquiry found faults before patient died

An internal investigation into the death of a patient at James Connolly Memorial Hospital (JCMH) in Dublin identified a number of system failures prior to her death, The Irish Times has learned.

A confidential report into the death of 38-year-old Michelle Tallon, a woman with intellectual disability, found that there had been "miscommunication/ misunderstanding between staff" which resulted in Ms Tallon not being fed for three days longer than was deemed necessary by her medical team.

"Medical staff state verbal instructions were given to withdraw the NPO [nil per oral] orders; this was not documented in the clinical records," the report said. "Nursing staff state they did not receive this instruction. The hospital did not have a specific policy relating to the day-to-day management of a "nil by mouth" order This may have led to the possibility of an order remaining in force for longer than it was intended."

She was also administered with a laxative via naso-gastric tube over a period of 30 minutes instead of over the recommended one hour and vomited up much of the liquid. Her lungs were later found to contain "infiltrate" and she was diagnosed with acute respiratory failure. Prior to her death at the hospital she was also diagnosed with MRSA.

Ms Tallon was admitted to the hospital on July 6th, 2005, after a second visit to the A&E department in four days. She had been vomiting and was not eating. She was later found to have a blocked and swollen bowel, which the hospital attempted to relieve through use of enemas and laxatives through naso-gastric tube.

A colonoscopy, to examine her bowel using a camera, was also recommended. However, following an acute deterioration in her condition, she was transferred to the hospital's intensive care unit suffering from acute respiratory failure. She died there on July 23rd. A postmortem found that she died of acute respiratory distress syndrome.

The report recommended that a team be set up to review record-keeping policies and referral systems within the hospital. It also said that guidelines should be developed around nil-by-mouth orders and a working group should be set up to review the management of constipation. And it recommended that additional training be given to staff involved in the care of patients with intellectual disabilities.

Ms Tallon's parents, Bernadette and Bernard Tallon, who had raised concerns about their daughter's treatment at JCMH prior to her death, said yesterday they were disappointed with the report.

"The report didn't answer the questions and we're very, very bitter," Mrs Tallon said. "She couldn't talk or walk, they didn't care because she was handicapped."

A spokesman for the Health Service Executive expressed sympathy to the Tallon family and said that the recommendations outlined in the report have been and are being implemented.