Grieving family welcomes call for fresh probe into death of Kells woman
A GRIEVING Co Meath family has welcomed a call by a coroner for a fresh review by health authorities into the death of a 50-year-old Kells woman who died in controversial circumstances over two years ago.
Grainne Maguire, Kilmainham and Gardenrath, Kells died by suicide on 7th June 2024.
The call by coroner Nathaniel Lacy for a fresh review by HSE Adult Mental Health Services follows an internal review carried out by the Serious Incident Management team in the wake of Ms Maguire’s death.
That team made a decision in September 2024 that no further review was required.
The inquest into the death opened last June but was not reported on to await the coroner’s verdict and recommendations which were issued in the last few days.
In the wake of the verdict, Ms Maguire’s family said that they felt the severity of her condition was not acted upon quickly enough when they reached out for help.
At the June hearing a family member said that Grainne’s GP Dr Hanley had received correspondence from the Crosslanes Drogheda Psychiatric Unit confirming that Grainne had been “prioritised as a community referral with Academy House in Navan”.
On follow-up by the GP an appointment was given for Monday 10th June. An inquiry was made as to whether or not a more urgent appointment could be made given Grainne’s condition “but there was no availability therein”.
Ms Maguire’s sister, Annemarie Flanagan, told the inquest in June that her sister’s partner, Joe Walsh had contacted herself and her brother on a bank holiday Monday to say that their sister was very agitated.
They as a couple had been trying to deal with her agitation by themselves for the previous 4-5 weeks but could no longer cope alone. Her struggles with mental health had been getting greater.
Annemarie and her brother Aidan had driven to her home and she was very concerned about the condition her sister was in. It was said Grainne was paranoid about various issues. They had phoned a nurse who took all the details, expressed the opinion that Grainne might be having an acute episode of psychosis and advised them to bring her to A&E Navan.
Ms Flanagan said that after a 3.5 hour examination doctors advised them to bring Grainne to the Drogheda Psychiatric Assessment Unit. She said they departed for Drogheda at 10.45pm and “waited for hours to be seen”.
They felt very uncomfortable due to Grainne’s anxiety. They said that they felt that patients in the waiting area “were not treated as sympathetically as they should have been” and they feared “this too might be the case with their sister”. Grainne was then seen by a doctor for 20-25m.
They were told that she was being discharged to the care of the community care day team as a matter of urgency.
Garda Gerard Coldrick gave evidence of having attending the scene of the death and meeting Ms Maguire’s partner Joe Walsh and later his sister Catherine Cregan.
Dr Orla Hanley had pronounced death at the scene. Consultant pathologist Professor Muna Sabah who carried out a post mortem on the deceased told the inquest the death would have been instantaneous.
In the last few days Mr Lacy issued a narrative verdict that Ms Maguire’s death was in accordance with evidence given by the pathologist.
He also issued a 440-word nine-item set of recommendations, the most prominent being that while the HSE had carried out an internal review into the circumstances of Ms Maguire’s death, in the light of the inquest and evidence given he recommended that “a further review now take place”.
Other recommendations
- A direct referral process should be implemented between GPs in Louth-Meath and the Drogheda Department of Psychiatry. This should be made available in cases where an acute psychiatric referral is required. If it is the case that such system is in place, all GPs should be reminded and aware of this together with the psychiatric unit (DDOP).
- A review of the assessment process in DDOP to take place to ensure that all examining psychiatrists are trained to be fully aware of “markers/red flags” consistent with a patient being at high risk of self-harming.
- That the DDOP and all treating and examining psychiatrists have a 24-hour access to a consultant psychiatrist for consultation in the background of patients presenting in acute psychotic state.
- Clear written and legible records should be made by every professional who interacts with a patient and their rationale for decision making on every medical record in DDOP.
- The DDOP should prepare a patient-focused safety plan for each patient when being discharged from DDOP and one that is pertinent to that patient’s individual circumstances.
- Whilst respecting the patient’s privacy and GDPR provisions, the DDOP should consult with family members to ascertain the gravity of the patient’s symptoms as to whether or not 24-hour monitoring is required for the patient’s safety.
- A patient’s discharge should include an emergency treatment plan, monitoring, review and communication
- That DDOP and Louth Meath Mental Health Services review the standard list of contacts given to patients leaving DDOP to ensure that the list is up to date and that the contacts and relevant telephone numbers are up to date and capable of receiving calls 24 hour and seven days weekly in urgent cases.
In a statement to Meath Chronicle, NSE NorthEast said it “acknowledges the profound impact that such tragedies have on families, staff, and the wider community, and extends its sincere sympathies to all those affected.”
“In addition to providing appropriate support, the HSE adheres to its established policies and procedures, including undertaking an internal review and liaising with the relevant statutory and community agencies.
“HSE Dublin and North East cannot comment on individual cases when to do so might reveal information in relation to identifiable individuals, breaching the ethical requirement on us to observe our duty of confidentiality.”
‘It is our fervent wish that Grainne’s death will lead to meaningful, lasting change’
FAMILY STATEMENT
The family of Grainne Maguire said that they were shocked at the decision of the healthcare team at the Crosslanes Psychiatric Assessment Unit in Drogheda to discharge her when her symptoms had not settled and she “remained in a very vulnerable state”.
The family’s statement was issued in the wake of the finalisation of the inquest by Coroner for Co Meath Nathaniel Lacy.
They recalled how their “beautiful sister” had suffered an acute mental health crisis in the Summer of 2024, her first ever mental health episode.
“We feel the severity of her condition wasn’t acted upon quickly enough when we reached out for help”.
They had sought assistance from the appropriate healthcare professionals in Our Lady’s Hospital Navan where she had been examined and sent directly to the Drogheda Psychiatric unit where she was further assessed. She had been discharged shortly afterwards and a further appointment was to be arranged in her home by the community mental health services. They then expressed their shock at her early discharge.
“Despite assurances that Grainne would be seen urgently, days passed without any appointment. As a family we did everything in our power to communicate the urgency of her situation to the relevant healthcare professionals and stakeholders. Tragically, our concerns were not acted upon in a timely manner and Grainne did not receive the treatment and support she so desperately needed”.
“We are utterly devastated by Grainne’s untimely passing. We have lost our beautiful sister and our lives will never be the same. The pain of losing her is immeasurable, made all the more difficult by the knowledge that the care she needed was not provided when it mattered most”.
The family expressed their sincere gratitude to the Coroner Mr Nathaniel Lacy for the time, care and consideration he devoted to the inquest into Grainne’s death.
“We welcome his narrative verdict and the significant recommendations he has made. We sincerely hope that these recommendations will be implemented within the mental health services in Louth and Meath and indeed across the country. It is our fervent wish that Grainne’s death will lead to meaningful and lasting change. No family should have to endue the heartbreak we have experienced over the past two years and no other life should be cut short because of failings in mental health care. Families in crisis must be listened to. Concerns must be taken seriously and urgent mental health needs must be met with timely and appropriate intervention. We would also like to thank our solicitor Ms Niamh Ni Mhurchu for her guidance and support through what has been an extremely difficult and daunting process. Grainne will forever be loved and missed by her family. We hope that the findings of this inquest will help prevent another family ensuring the same devastating loss.”