Family of woman who died with two broken legs at care home highlight HSE’s breach of care

David Raleigh

An elderly woman died after suffering two broken legs at a HSE care home after staff did not call for medical assistance for the woman for two days.

The family of Mary Melody, 89, who died seven days after an unwitnessed incident at Raheen Community Hospital, Tuamgraney, Co Clare, spoke out and urged people to regularly visit loved ones in care to try to ensure their safety.

Immobile and wheelchair bound, Mary Melody allegedly fell out of her chair in an unwitnessed incident at the care home on July 3rd, 2021, and died seven days later at University Hospital Limerick (UHL).

Speaking out for the first time since his mother’s death, Ms Melody’s son, Pat Melody, and her daughter, Moira Lenihan, both called on the HSE to ensure doctors are called whenever a person in their care suffers a fall or injury.

They also urged people to make regular checks on their loved ones in care.

“If you have family in care, for God’s sake, go and visit them, because you just don't know what’s going on after you walk out the door,” said Pat Melody.

“It was a complete disaster for us. You put someone into a nursing home, you’re hoping they’re going to be taken care of,” he added.

Staff said they did not call a doctor after the alleged fall, because they said they did not see any sign of broken bones.

They believed Ms Melody’s pain was due to a pre-existing osteoarthritis condition, which they were treating with pain medication.

Staff acknowledged Ms Melody screamed in pain for two days, and prayed to God to take her, as she was in such pain.

She was eventually transferred by ambulance to UHL, where scans confirmed fractures to both her femurs.

Staff at UHL flagged their concerns about the “delay” in Ms Melody being presented to the hospital 48 hours after the unwitnessed incident at the care home.

Palliative care was provided at the hospital for the mother of five who passed away on July 10th, seven days after the fall.

Last year, the HSE admitted in an out-of-court personal injuries settlement, taken by Ms Lenihan, that it breached its duty to provide residential care and treatment to Ms Melody between July 3rd and July 5th, 2021.

Ms Lenihan said “you wouldn't do to an animal” what her mother experienced at the care home, saying “what went on there was ridiculous”.

“You’d like to think procedures were followed, but we don't know. I suppose (our) main point is that (staff) should contact a doctor if somebody falls. It was wrong and that’s it. There is no other way around it.”

Ms Lenihan and Mr Melody urged people “not to forget” about loved ones in care homes, hospitals, or any other care environments.

“How many more times did (staff) not phone a doctor for someone? I just couldn't believe that it actually happened. It’s obviously still upsetting us, as it would, and there’s nothing we can do about it,” said Ms Lenihan.

“To get the HSE to admit failure in mam’s care, is, I suppose, better than nothing, but we are still searching for answers,” she said.

They both praised “the local community” for rallying around them.

In statements prepared by staff for Ms Melody’s inquest, held at Limerick Coroner’s Court last year, staff said Ms Melody continued to scream in pain for two days after her alleged fall, particularly when she was being moved.

Staff continued to hoist her out of her bed for showering and to and from her chair.

Prepared statement

One of the care home staff said in a prepared statement at Ms Melody’s inquest that Ms Melody was “calling out the Rosary and asking for God to take her, she was in so much pain”.

This staff member said they were concerned for Ms Melody, and when they shared these concerns with the care home management, an ambulance was eventually called.

The incident was reported to HIQA, the state health watchdog, and the HSE investigated the matter internally.

Pat Melody and Moira Lenihan said they have heard nothing from HIQA, and they are “still searching for answers” as to how their mother died.

In statements at the inquest, Ms Melody’s family said staff at Raheen gave them conflicting reports about their mother’s injuries, including that she fell from her chair while exiting a prayer room, and that she slipped or fell from her chair in a sitting room while tea was being served to other residents.

Ms Melody’s daughter, Helena Walsh, stated that it was “very upsetting” for the family to read in the Raheen’s Incident Report that their mother’s alleged fall was actually not witnessed and said, “we wonder what actually happened to our mother”.

Staff at the care home said they performed a “full body check” on Ms Melody following her alleged fall. They said they assisted her back into her chair and that she did not complain of pain or appear to have broken bones.

Ms Melody’s son, Seamus Melody, stated he visited his mother in the care home shortly after the alleged fall incident. He said he noticed that when a staff member tried to lift his mother’s legs back onto the step of the wheelchair, “she roared in pain” and sought painkillers.

One of the staff stated they were following the HSE care home’s policy not to call a doctor as they felt Ms Melody was in a “stable” condition and “in no obvious distress”.

A “narrative” verdict of the events was returned at Ms Melody’s inquest, and the Limerick coroner found that the cause of death was in line with the medical evidence that Ms Melody suffered two broken femurs, that she suffered a sudden heart and lung failure, coupled with heart disease, blood clots, and a historic faulty heart valve.

An incident report compiled by a senior nurse commissioned by Ms Lenihan’s solicitors stated that, in their view, “red flags were missed” by the care home staff after Ms Melody’s alleged fall, and that “the change in her clinical picture within 24 hours was not acted upon”.

The report described Ms Melody’s injuries as being “a seriously significant event”, and that “the outcome of this fall would have, and unfortunately did, greatly impact her mortality”.

The HSE, which operates Raheen Community Hospital, was asked a number of questions, including if it had learned lessons about how falls are responded to in its care.

In response, HSE Mid West said: “We can confirm that we have implemented the recommendations made to ensure best practice in Raheen CNU, including full medical review by a doctor of any resident who falls, a nominated person to communicate with family members after an incident, and comprehensive training in falls management for care staff.”

“We acknowledge the adverse findings in the HSE review of this case... and it’s a matter of profound regret for HSE Mid West when there is a shortcoming in the care of our patients.”

HIQA said: “While nursing home providers are required to notify HIQA’s Chief Inspector of Social Services of certain events, please note the Chief Inspector does not receive information on named persons. However, the Chief Inspector did receive two notifications from this nursing home that align with the dates and circumstances outlined.”

“One of those notifications advised that the circumstances of an unexpected death were the subject of a coroner’s investigation.”

“The Chief Inspector does not have a remit to investigate individual deaths in a nursing home, so would not have conducted an investigation into the information that was received.”

“Inspectors review and follow up on any such information received, and can take a number of actions based on this, such as: using the information on the next scheduled inspection; requesting follow-up information from a provider; requesting a plan to address an identified issue; carrying out another inspection; referring the information that we have received to another appropriate agency.