10-year fight for justice for man who suffered agonising death

‘The constant stonewalling by the HSE and its attitude over the past 10 years has been very distressing’

MURIEL Kiely is still haunted by the last desperate words of her long-time partner Jimmy as he died gasping for breath.

“He cried ‘no oxygen’. He was in terror and knew he had no hope,” she said yesterday.

Jimmy Grogan (73) passed away within 30 minutes of his transfer from Ennis Hospital to the HSE-run nursing home Regina House in Kilrush, Co Clare, which could provide him with only five litres of oxygen.

“Jimmy needed 15 litres of oxygen per minute or else he would die.”

The tragedy, which an independent HSE-commissioned report yesterday bluntly described as “horrific”, took place in November 2007. But Ms Kiely has spent the last decade searching for answers about why the terminally-ill pensioner was moved from the hospital.

“We knew he had not long to live but it was the manner of his death which left us so distressed,” she said.

The report said the death was both preventable and predictable. It amounted to a “catastrophic failure of healthcare”.

The couple, who were both widowed with children, were together for 18 years.

Mr Grogan, who was a retired insurance agent, suffered from pulmonary fibrosis and relied on oxygen at their home for several years.

He was admitted to Ennis Hospital on November 21, 2007, but it was decided to discharge him to the public nursing home in Kilrush, where the couple lived, two days later.

“The decision to discharge him was taken while I was not at the hospital,” Ms Kiely said.

He was put in an ambulance that carried out routine transfers despite his critical condition.

“We had to wait for an hour because the ambulance needed to collect another patient. It was a freezing cold November day.”

Mr Grogan was hooked up to sufficient oxygen during the 27-mile journey, which seemed to go on for an “eternity”.

“Jimmy was taken into the nursing home and placed in a room. I was asked to wait outside.

“But then I heard him call out my name. I rushed in.”

Muriel found him in agony and “turning black blue and purple”.

Staff struggled to save him but had access to only five litres of oxygen per minute. The ambulance that might have provided extra oxygen had already left.

The nursing home has since increased the capacity of oxygen it can deliver to 15 litres per minute.

Ms Kiely, a former teacher of English and maths, could not tolerate what she saw as a catalogue of failures in his care.

“I made a complaint and received a response in February 2008.

“It did not acknowledge the adverse event, apologise or address the issues.”

One of the most hurtful claims was that Ms Kiely asked for his transfer to the nursing home. The independent report is clear this is not correct and she bears no responsibility for the decision to discharge him.

This was also emphasised in a letter of apology which she has received from HSE chief

Tony O’Brien.

Ms Kiely has been supported in the last decade by patient advocate Jim Reilly, who was previously with Patient Focus.

Other reviews followed, but it was not until this week that the independent report, commissioned by Mr O’Brien, shed more light on the events.

It found the inability of the HSE to identify failures, accept and apologise for them was “inexplicable”.

It highlighted weaknesses such as the lack of a proper handover of the patient to the paramedics who came to the hospital to collect him.

“Effective planning and communication was absent” between the healthcare professionals caring for him, the report added.

Staff in the nursing home were wholly unprepared to cater for the patient who needed such specialised care.

Ms Kiely said yesterday she was now seeking a meeting with Health Minister Simon Harris.

“I accept Mr O’Brien’s apology but the report raises serious concerns about the many aspects of my partner’s care and also the adequacy of a review carried out by the HSE which took three years.

“The constant stonewalling by the HSE and its attitude over the past 10 years has been very distressing.”

Her hope is that lessons are learned from the ordeal.