An inquest has recorded an open verdict in the tragic case of a vulnerable elderly dementia patient who was found dead in her nursing home room, her head covered with a duvet, while another dementia patient sat calmly nearby.
Marcella O’Sullivan, 95, formerly of Blackpool in Cork, was found dead in her bed in her room at Brídhaven nursing home in Mallow, Co Cork, just after 8pm on April 13, 2022.
A second dementia patient, a woman in her 70s, who had visited Ms O’Sullivan’s room unsupervised more than 100 times that day, was found sitting in a chair by the door. That woman has since died.
The jury ruled that a third party was involved in lifting the duvet over Ms O’Sullivan’s head but could not say who it was, or whether it occurred before or after her death.
Coroner Frank O’Connell said it was “a situation which should never have arisen”.
Ms O’Sullivan had severe dementia and was a highly vulnerable and high-dependency resident.
She was on a liquid-only diet, she was not capable of communicating, and she was not physically capable of pulling a duvet up over her head.
However, the inquest heard that the second dementia patient, described by nursing home staff as a “roamer”, had entered Ms O’Sullivan’s room unsupervised 122 times that day, with CCTV footage showing her in the room 53 times in the space of one 67-minute period.
While most of the visits lasted just a few seconds, one visit, shortly after Ms O’Sullivan was fed and before her body was discovered, lasted 13 minutes.
The inquest heard that Ms O’Sullivan was fed on the evening of April 13, that her eyes were open, she was comfortable, and the duvet was at her waist when the care assistant left.
However, when staff checked her at 8.03pm, they saw the duvet over her head, and when they pulled it down, they found her unresponsive with traces of vomit around her mouth.
The alarm was raised, but she was pronounced dead.
Brídhaven nursing home expressed their deepest and most sincere apologies for the failings identified. File picture: Denis Scannell
Given the circumstances, gardaí were alerted and they conducted a full forensic examination.
Det Inspector John O’Connell said they could find no evidence to indicate precisely what had happened in Ms O’Sullivan’s room, and they were not able to interview the other dementia patient after an expert ruled she was not cognitively capable of answering questions or even of recalling the events of April 13.
A file was submitted to the DPP, which directed that there be no criminal prosecution.
Det Inspector O’Connell said it was possible that Ms O’Sullivan vomited and died, and the duvet was lifted over her head by the second woman afterwards, or that the second woman lifted the duvet over Ms O’Sullivan’s head, that she then vomited in distress, and aspirated the gastric contents, resulting in her death.
However, he said the second dementia patient had no history of aggression and there was no indication that she ever intended to harm Ms O’Sullivan.
Assistant state pathologist Margot Bolster described it as a complex case, and reviewed it with colleagues.
She said the amount of gastric contents vomited was not consistent with the normal regurgitation of food after eating and, on balance, she believed Ms O’Sullivan died from aspiration of vomit after the duvet was lifted over her head.
Mr O’Connell said the families of both women had been put in “an awful position” and he praised them for their dignity.
Brídhaven nursing home issued an apology through Christian Douglas BL, expressing their deepest and most sincere apologies for the failings identified.