Paul Murphy
A grieving Co Meath family has welcomed a call by a coroner for a fresh review by health authorities into the death of a 51-year-old Kells woman who died in controversial circumstances over two years ago. Grainne Maguire, Kilmainham and Gardenrath, Kells died by suicide on 7 th 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 Graine had been “prioritised as a community referral with Academy House in Navan”. On follow-up by the GP an appointment was given for Monday 10 th 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 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 four to five weeks but could no longer cope alone. Her struggles with mental health had been getting greater. She and her brother Aidan had driven to her home and she was very concerned about the condition her sister was in. She 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 20-25 minutes. 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 Wade 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.
Meath County Coroner Nathaniel Lacy.
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, kin 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/redflags” 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 into 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.
