A WOMAN who took her own life and that of her nine-year-old daughter had given health professionals advance warning of her intentions, a report has revealed.
An independent inquiry into the deaths of Madeleine O'Neill (40) and her daughter, Lauren, in their Carryduff home on the outskirts of Belfast in July 2005, highlighted a number of failings in the care provided to them.
This included the disappearance of notes which could have alerted staff in Gransha Hospital in Derry about her suicidal intentions.
The report also claimed that had health professionals acted properly on the threats to Lauren's life, it could have been prevented.
Ms O'Neill had been receiving treatment from her GP for a number of years for depression but there was a marked change in her demeanour in May 2005, two days before she took an overdose of medications.
One month later, in sessions with a private counsellor, she indicated she was again having suicidal thoughts and made a reference to taking Lauren with her.
This prompted her GP to contact Knockbracken Healthcare Park in south Belfast about admitting Ms O'Neill as a voluntary patient but initially she encountered a bed-availability problem.
After she was admitted, it was decided by her parents she should be transferred to Gransha Hospital, where she stayed for almost a fortnight before she was discharged at her own request.
However, throughout her stay, staff at Gransha were unaware of any threat to Ms O'Neill's daughter, Lauren, because they did not see the notes from Knockbracken.
Ms O'Neill was diagnosed instead as suffering from a major or moderate depressive disorder.
On July 7th, a file compiled by Gransha staff was taken to the Cityside Community Mental Health Team's offices in Derry.
Two days after Ms O'Neill killed her daughter and herself, the file was retrieved and was found to contain the Knockbracken notes.
"The independent inquiry carried out a detailed investigation to determine how these notes had been placed in the file but was unable to reach a conclusion," the independent team, headed by retired Department of Health official Drew Boyd, said.
The report said: "Independent inquiry panel members were concerned in relation to the process for the transfer of documentation between Knockbracken and Gransha hospitals; the lack of communication between the two hospitals to ensure and confirm the safe arrival of the patient at Gransha Hospital; and the fact that staff at Gransha Hospital did not seek information from Knockbracken when documentation did not arrive with the patient."
The inquiry team also:
- criticised the communication between both hospitals and the patient's family, with no evidence of Ms O'Neill's estranged husband being informed of the threat to Lauren nor of him being involved in discussions about the impact of her illness on her ability to care for Lauren. Nor were relatives involved in discharge planning or future care arrangements for her;
- expressed alarm that many staff lacked a basic awareness of child-protection and children-in-need issues. The report noted: "It is clear from the panel's analysis that the threats to Lauren's life were known to practitioners and staff at a number of points but no direct action was taken to deal with or minimise the risk. It was the panel's view that had direct referrals been made when Madeleine expressed a threat to Lauren's safety and wellbeing, Lauren's death could have been prevented.";
- was concerned that Madeleine did not appear to have received adequate care and risk assessment at Knockbracken and Gransha hospitals and believed she should have stayed in Knockbracken longer until a more thorough assessment was completed over a longer period of time. Concerns were also expressed about the levels of observation of her; and
- found there was no evidence of any joined-up approach by the multidisciplinary teams caring for Ms O'Neill in both hospitals, with poor communication between them. - ( PA)