A woman who had a severe form of multiple sclerosis (MS) died during a respite stay in a care home when her head became trapped between her bed and the cot sides, an inquest heard yesterday.
Linda Ryan (46), Chapel Lane, Malahide Road, Swords, Co Dublin, died at the MS Care Centre, Bushy Park, Terenure, on February 27th, 2005, when she fell out of her bed and her head and neck became trapped between the rail of the cot side and the bed. She was pronounced dead at St James's Hospital that day.
The inquest at Dublin City Coroner's Court was unable to establish how Ms Ryan, who was very debilitated as a result of her illness and was unable to move, came to fall or slip out of bed, the court heard.
A postmortem examination carried out by Dr Seán O'Broinn revealed that Ms Ryan died from positional asphyxiation. The asphyxiation was caused by the position in which she fell and which, due to her condition, she was unable to correct, according to Dr O'Broinn.
Ms Ryan, a regular patient at the care home with her husband, Tony Ryan, who is also wheelchair-bound, arrived at the Bushy Park centre on February 26th for a week's respite, the court heard.
She usually stayed in room seven, a twin room with her husband, but on this occasion Ms Ryan was admitted to room nine because it was nearer the nurse's station.
However, the bed in room nine was different to the bed Ms Ryan usually had, as it did not have full-length rails, but rather rails that covered approximately one-third the length of the bed.
Ms Ryan, who was able to talk, went to bed at 11pm on February 26th in good form.
Aishling Creegan, a care worker at the centre, told the inquest she and a nurse on the night shift, Anne Murphy, checked on Ms Ryan and turned her at 12.20am and at 4.30am on February 27th.
They went to her door at 7am but decided not to move her so as to not disturb her sleep.
Later, between 9.15am and 9.20am, nurse Rose Tucker entered Ms Ryan's room and found her trapped.
When the inquest into Ms Ryan's death first opened on July 21st, 2006, nurse Tucker said that on entering the room the patient was not lying in her bed and she noticed the top of her head at the far side of the bed.
Personnel from Dublin Fire Brigade arrived at the centre at 9.30am and removed Ms Ryan to St James's Hospital. Paramedic Dermot O'Rourke told the court that Ms Ryan displayed no signs of cardiac activity.
Coroner Dr Brian Farrell told the court that he would like to have been able to see the bed and have it examined in the public interest, but "we don't have that evidence". The room in which Ms Ryan died was subsequently refurbished and the bed sent to a metal recycling firm, the court heard.
He said he would write to the Irish Nursing Homes Organisation with regard to a number of recommendations made by counsel for the Ryan family, William James.
In light of the failure to check on Ms Ryan every two hours on the night in question, Mr James recommended that all instructions given in relation to the care of patients should be followed thoroughly and called for a proper assessment in relation to the type of bed railings suitable for patients.
Counsel for MS Ireland, John Gleeson, said there had been a substantial review of procedures in the MS Care Centre since Ms Ryan's death and new procedures introduced. All beds are now fitted with full cot sides.
Dr Farrell expressed his condolences to the Ryan family.