Consultant psychiatrists have been found inadequate in their treatment of Anne O'Rahilly, writes Martin Wall.
On September 20th, 2002, Anne O'Rahilly (21) killed herself in a bathroom of the acute psychiatric unit at the Mid Western Regional Hospital in Limerick.
Her death followed a series of communications and systems failures on behalf of doctors, nurses and the mental health services in general and which were identified in an expert group report. This examined over the last year the treatment and care of Ms O'Rahilly.
Commissioned by the Mid Western Health Board, the report is critical of consultant psychiatrists and the mental health services and has made 36 recommendations.
The health board has accepted these but some relating to the development and improvement of services at the psychiatric unit in Limerick will take millions of euro to implement.
The report states that Anne O'Rahilly had suffered episodes of depression from age 18.
Her condition relapsed in summer 2002 and in September her GP sought to refer her to a private psychiatric hospital, St Patrick's in Dublin.
She had previously been a private patient of Dr Peter Kirwan, a consultant psychiatrist at the Limerick hospital.
But the decision to go to Dublin effectively terminated her clinical involvement with Dr Kirwan.
Anne O'Rahilly was admitted to St Patrick's in Dublin on September 13th. According to the report, however, five days later an unidentified member of the hospital's accounts department contacted her mother and told her that her daughter had inadequate health insurance cover.
"Mrs O'Rahilly was asked to decide by 10 a.m. the following day whether the family would be in a position to fund their daughter's continuing hospital stay from their own resources."
The family contacted the consultant at St Patrick's, Dr John Cooney, who advised that Ms O'Rahilly required continuing in-patient care and, at her mother's request, he undertook to arrange her admittance to her local psychiatric unit in Limerick as a public patient.
Dr Cooney contacted Dr Kirwan, clinical director of mental health services in Limerick, who advised that as a public patient, Ms O'Rahilly would be under the care of another consultant psychiatrist, Dr Peter O'Hara.
Dr Cooney drafted a handwritten letter for Dr O'Hara which emphasised his concern that Ms O'Rahilly was a "significant suicide risk at that time given her level of agitation and despair".
The review group found that despite being identified as a suicide risk, Ms O'Rahilly was discharged from St Patrick's late in the evening into the care of her parents. They then undertook the three-hour train journey to Limerick.
"In the opinion of the review committee, it does not appear that due consideration was given by the transferring clinician, Dr Cooney, nor the receivingtreating clinicians, Drs Kirwan and O'Hara to the timing of Anne O'Rahilly's elective transfer, both for herself and for her parents who escorted her."
The report also maintained that communication between Dr Kirwan and treating clinician Dr O'Hara had been "insufficient, indirect and lacking in detail".
On arrival in Limerick, Ms O'Rahilly was assessed by the junior doctor on call, Dr Ken Cahill, a trainee on the Mid Western Health Board general practice vocational training scheme.
The report found Dr Cahill's training and supervision in adult psychiatry was limited and that his predominant experience in psychiatry had been in the sub-specialty of children and adolescents.
The report also found that the nurse who conducted Ms O'Rahilly's initial nursing assessment did not read the detailed clinical information forwarded from St Patrick's, although it was available.
It also found there was no evidence that an inventory of Ms O'Rahilly's personal property had been carried out.
The following morning on his ward round, the treating consultant, Dr O'Hara, read Dr Cahill's admission notes from the previous night and some, but not all, of the 22 pages sent from St Patrick's.
The report found Dr O'Hara failed to notice the handwritten letter addressed to him from Dr Cooney which registered unease about the risk of Anne O'Rahilly harming herself and included details of medication that had relieved her agitation and distress.
Dr O'Hara delegated to one of his non-consultant doctors, Dr Shekani, to see his patient, carry out a mental examination and discuss a treatment plan with him.
The report said Dr Shekani indicated that Ms O'Rahilly wanted to meet the consultant but that Dr O'Hara decided to defer this meeting until the following Monday. A nurse informed Dr O'Hara that the collapsible curtain rails surrounding Anne O'Rahilly's bed had become detached, the report says.
"This was not judged to be significant by Dr O'Hara as curtain rails regularly came down during normal usage."
At around 12.10 p.m. Anne O'Rahilly was seen by two nurses lying on her bed. This was the last time she was seen alive.
At around 12.20 p.m. a nurse looked for Anne but could not find her either in her room or in the canteen.
The nurse asked a colleague to look around for her.
"He recalls the dining room being very noisy and not hearing the name of the person being sought. However he recalls that a girl with red hair was mentioned.
"A patient informed him that 'she was in the dining room' and upon his return to the dining room, he saw a female patient with red hair whom he assumed was the person in question."
The report says he pointed her out to the other nurse and "mouthed" - as it was very noisy - that she was over there, pointing to the red-haired girl.
"It was only after the tragic event, when he saw Anne O'Rahilly's body, that he realised he had mistakenly identified another patient."
Around 1.15 p.m. the body of Anne O'Rahilly was found hanging from the shower railing in the bathroom.
An emergency team arrived a few minutes later but was unable to revive Ms O'Rahilly and she was pronounced dead at 1.55 p.m.
The O'Rahilly family are planning legal action against the Mid Western Health Board and have submitted the findings of the review group report to the Medical Council, the governing body for doctors in Ireland.