An inquest jury has returned an open verdict in the case of a 95-year-old woman with advanced dementia and physical limitations who was found dead in her nursing home bed with a duvet over her head, having suffered from aspiration of vomit.
Brídhaven nursing home in Mallow, Co Cork, apologised for the failings identified in the care of Marcella O'Sullivan, who was found dead in her bedroom at the home shortly after 8pm on 13 April 2022.
An inquest in Mallow heard from medical staff at the home that another patient, who also had severe dementia, was in the room when they entered at 8.03pm that night.
Coroner Frank O’Connell was told that the other woman was a "roamer" who entered the room of other patients and picked up items.
CCTV footage analysed by gardaí indicated that she went to the room of Ms O’Sullivan over 100 times on the day she died. The vast majority of her visits lasted a few seconds.
The evidence was that the duvet was not over the head of Ms O’Sullivan when she was last seen by staff shortly after 5pm.
Mr O’Connell said that it was accepted that Ms O'Sullivan was physically unable to lift the duvet herself.
Assistant State Pathologist, Dr Margaret Bolster, carried out a postmortem on the deceased. She said that the case was complex in nature.
Dr Bolster said it was her opinion, and those of her colleagues, that Ms O’Sullivan died after her airways were covered by the duvet leading to an aspiration of her gastric contents.
She said that there was a history of dysphagia (difficulty of swallowing) which meant that the pensioner was on a liquid diet.
Dr Bolster noted that the duvet cover was "less breathable" as it was water proofed.
She said that the deceased had a bruise on her tongue. There was also a large amount of vomit.
Ms O’Sullivan had been fed by staff at around 5pm that day. She was comfortable, had her eyes open and the duvet was at her waist.
She was not checked again by staff until 8.03pm, when she was found dead.
A decision was made to contact gardaí arising out of the circumstances in which Ms O’Sullivan was found dead. A file was prepared for the DPP.
Det Insp John O’Connell said that the woman who was in the room when Ms O’Sullivan was found dead was assessed by an expert geriatrician.
He deemed her not capable of recalling the evening in which Ms O’Sullivan died. This woman has also since passed away.
Det Insp O’Connell said that the DPP directed that no criminal prosecution be brought in the case.
He said they were left with two possible explanations.
The first scenario was that Ms O'Sullivan vomited and died with the duvet then being placed over her head by the other patient.
Det Insp O’Connell said that the second scenario involved the other patient putting the duvet over Ms O'Sullivan's head and her aspirating her gastric contents and dying.
Det Insp O'Connell said that there was "no clear evidence", forensic or otherwise, to suggest that the other woman intended to cause harm to Ms O’Sullivan.
He said that the other woman "had no history of aggression".
The six-person jury recorded an open verdict. The foreman said that they were all of the belief that a third party put the duvet over the head of Ms O’Sullivan.
However, they could not say who that person was or whether it occurred before or after she died.
Coroner Frank O’Connell offered his heartfelt condolences to the family of Ms O’Sullivan, whom he said had passed "on to her reward".
He thanked the O’Sullivan family for the enormous dignity they had shown during the inquest.
He said that it was unfortunate that both families had been put in an "awful position" arising out of the controversy that had occurred.
Barrister Khristian Douglas apologised to the family of Ms O’Sullivan on behalf of Brídhaven nursing home.
"Brídhaven nursing home wishes to express our deepest and most sincere apologies...(for) the failings identified. We understand the pain and distress this has caused," he said.
Ms O’Sullivan was the "dearly loved wife" of the late William (Billy) and "much loved" mother of Rita, Ann, Edward, Martin, Anthony and Joseph.
She was predeceased by her children Mary and Tony.
