Timeline of Ms Y case
HSE draft report tracks Ms Y’s care from her arrival in Ireland in March to her discharge after Caesarian section in August
“Ms Y has had no fluids for 40 hours. She is met by consultant psychiatrist 4 who records: ‘Ms Y was an ongoing suicidal risk.’ Photograph: Bluestone/Science Photo Library
The following is a chronology of what happened to Ms Y, from the time she arrived in the Republic on March 28th until her infant was delivered by Caesarean section in August, when she was 26 weeks pregnant. It draws on the first draft report from the Health Service Executive (HSE) on her care, which states on each of its 78 pages: “This is a draft document and can only be considered as such. This document can be expected to contain factual/clinical inaccuracies and/or information that may require additional clarification.”
The HSE report team has not yet spoken to Ms Y for the report but has invited her for interview. She is considering whether to engage with the review team.
Ms Y arrives in Ireland. “She claimed asylum,” the draft report states.
At a health screening Ms Y finds out she is pregnant. “Ms Y became very distressed and stated she could not be pregnant, that she could not have a baby and that no one could know . . . Ms Y stated that she had been raped in her own country.” Staff nurse 1 makes appointment for Ms Y at the Irish Family Planning Association (IFPA) for following Tuesday.
Ms Y attends appointment at IFPA. “All options were discussed with Ms Y, who was visibly very upset,” the draft report says. The legal situation is explained to Ms Y and she is told it may be difficult to travel for an abortion because “of her status”. Nevertheless, a scan to determine gestation is planned and the support-and-referral service at the Immigrant Council of Ireland (ICI) is to be contacted for information on travelling.
IFPA counsellor 1 calls the immigration council’s support-and-referral co-ordinator for advice on Ms Y’s travelling.
Ultrasound scan dates pregnancy as eight weeks and four days. Estimated due date is November 9th. Counsellor 1 leaves message with the immigrant council regarding Ms Y.
The immigration council tells counsellor 1 the process of getting travel documents from the Irish Naturalisation and Immigration Service (INIS) could be “lengthy”. It is agreed a second scan is needed.
Counsellor 1 refers Ms Y case to a senior colleague, counsellor 2. Counsellor 1 is going on leave and “was finding the case too difficult”.
Ms Y attends counsellor 2. The difficulties regarding travelling are explained to Ms Y. “Ms Y appeared extremely upset at the prospect of not being able to travel.”
INIS responds to the immigration council about Ms Y’s case. It indicates it would normally take six to eight weeks to process an application for temporary travel documents “but cases such as Ms Y’s were given priority” and it would take two to three weeks. Her application would be “processed as quickly as possible”. The immigration council communicates this to IFPA by email and requests confirmation of the stage of Ms Y’s pregnancy. The council gets no written response at this time but receives a call “sometime over the following couple of weeks”.
Ms Y attends clinic for second scan. Pregnancy now 14 weeks’ gestation.
Counsellor 2 contacts the immigration council regarding Ms Y’s case.
The immigration council’s support-and- referral co-ordinator asks counsellor 2 if Ms Y still wants to travel for a termination.
“Counsellor 2 indicated . . . there were still some issues to be sorted out and that Ms Y was ‘stressed’. The co-ordinator formed the view that Ms Y might have changed her mind about travelling as it was the co-ordinator’s experience that this could happen.”
Co-ordinator offers that Ms Y can come to the immigration council directly so it could assist her with completing the paperwork. Counsellor 2 says Ms Y is “vulnerable”. It is agreed IFPA will contact the co-ordinator if Ms Y needs assistance with paperwork. The immigration council has “no further contacts from the IFPA in relation to Ms Y’s case”.
Counsellor 2 contacts staff nurse 1 and explains she will give Ms Y visa application documents. She says Ms Y will need to fill them in and get passport photographs signed by a garda. Counsellor 2 advises Ms Y to speak to a community welfare officer about financial help.
Ms Y has a third counselling session with IFPA. During the two-hour session the counsellor suggests she consider adoption. Ms Y says she “would rather die than have this baby”. Counsellor 2 fills out travel application documents with her. She tells Ms Y she will need €120 to accompany the application. They go through costs, including €300 for a flight to the Netherlands and €700 for a termination at the Casa Clinic in Leiden, that total €1,300. IFPA does not receive the completed application for travel documents from Ms Y. She does not return to IFPA.
Counsellor 2 records a plan to follow up with Ms Y and staff nurse 1 on Monday, May 26th. There is no record in the report that counsellor 2 does this.
Ms Y has an appointment with a psychosocial worker from the Centre for the Care of Survivors of Torture (Spirasi) in her accommodation, to complete forms required for a medical-legal report with regard to her “asylum status”.
Ms Y is seen by a doctor at Spirasi “for the purpose of providing a medico-legal report for Ms Y’s solicitor”.
The doctor finds Ms Y “was sad and depressed but not . . . actively suicidal”. The doctor writes to GP in Ms Y’s accommodation with concerns about Ms Y. She also calls the accommodation asking to speak to the GP. The GP is not available and the doctor speaks to a clerk who tells the doctor Ms Y has not been seen by the GP, but that Ms Y is attending the IFPA.
The Spirasi doctor says she is concerned about Ms Y being in a room on her own but is satisfied Ms Y is seeing the IFPA. The doctor writes a report for the medical unit at the Reception and Integration Agency (RIA), which operates direct provision centres, saying Ms Y “had been abducted in February 2014 and beaten and raped repeatedly” and is pregnant as a result. The doctor records that “Ms Y was very traumatised and . . . was being referred urgently for psychological support”.
“Ms Y was very distressed and had a strong death wish,” the doctor says. She strongly recommends Ms Y not be moved from her accommodation until the baby is born and Ms Y is more “psychologically robust”.
The Spirasi doctor writes to the GP in Ms Y’s accommodation outlining concerns about Ms Y’s psychological wellbeing and states Ms Y has a “strong death wish”. The GP informs the report team he or she did not receive this letter.
RIA receives a handwritten letter from Ms Y requesting transfer from her accommodation. She will later say she wanted to move as she didn’t want anyone she knew to know she was pregnant. Staff nurse 1 will say she was unhappy about transfer “but that she did not know at the time if Ms Y was still pregnant or not”. She also thought Ms Y was still attending IFPA.
Ms Y moves to other accommodation. Staff nurse 1 contacts IFPA, leaving message for counsellors 1 and 2.
Ms Y finds another GP near her new accommodation and registers as a patient.
Counsellor 2 returns call to staff nurse 1. Counsellor 2 is anxious Ms Y be put in touch with crisis pregnancy counselling at her new accommodation. She tells staff nurse 1 she had been waiting for Ms Y to return the completed travel documents. Staff nurse 1 says “she suspected that Ms Y had requested the move to . . . as she might have a termination of pregnancy arranged for her” at her new location.
Ms Y presents at her new GP for an appointment. She says she wants to see a psychologist as she wants an abortion. The GP refers her for an outpatient psychiatric assessment. He contacts staff nurse 1 and learns Ms Y is 22 weeks pregnant.
Ms Y attends a group meeting hosted by Spirasi.
Ms Y attends the new GP again. She tells him “she did not wish to go ahead with her pregnancy and that she would rather be dead”. The GP believes she needs a psychiatric assessment. He writes a referral letter and calls the manager at Ms Y’s new accommodation asking them to arrange transport for her to a mental health hospital.
She is assessed by a consultant psychiatrist that evening and is admitted as a voluntary inpatient. “It is documented that Ms Y’s presenting symptoms were as follows: feeling very low, self-isolating, poor appetite, feels abandoned by everyone/no help given/ feels deceived; wants to terminate pregnancy, has nightmares and flashbacks of rape; says pregnancy resulted from rape . . . determined to end her life rather than have baby; feels hopeless and helpless.”
Ms Y is assessed by consultant psychiatrist 1. When told it is too late for an abortion she starts to cry and “and stated that she was going to commit suicide and that she had a plan and . . . she then gave details of the plan”. Psychiatrist 1 tells her she will need to see an obstetrician. “Ms Y indicated that she was not going to give birth and that she was going to die.
“Ms Y indicated she had been told ‘all the time’ that she would be helped and that time had passed and now it was too late . . . Throughout the interview Ms Y continued to state that the only way she could be helped was by carrying out a termination . . . and if this did not happen she would kill herself.”
She refuses offers of help from mental health services and “stated she would not stay in hospital and that she would go home to ‘end it’ ”.
Psychiatrist 1 tells her if she attempts this she will have to be detained under mental health legislation. “There was no evidence of psychosis.” Ms Y’s conversation is “very fixed . . . There was evidence of suicidal intent.”
Ms Y is transferred to a maternity hospital. A scan establishes she is 24 weeks pregnant, with a due date of November 12th. She is aware she will be detained under mental health legislation if she tries to leave, so she agrees to stay. She is to have one-to-one nursing care and metal cutlery is “to be avoided” at meals.
She is seen by a consultant obstetrician who tells her the baby is viable. She tells of her “plan to kill herself if the pregnancy continued”.
Ms Y refuses her supper at 7.30pm and refuses fluids, telling staff she “just wanted to die”.
Consultant psychiatrist 1 assesses Ms Y. Clinical impression document says she is detainable under the Mental Health Act, that she wants the baby dead, “that this is not based on a mental health disorder, this was a choice”.
Ms Y continues to refuse food and fluids. Social worker from the adult mental health services contacts child protection services “because of possible child-protection issues that might arise following the delivery of Ms Y’s baby”. A maternity social worker is assigned to Ms Y. Consultant obstetrician X states: “The hope was that Ms Y could be maintained on the ward for as long as possible and hopefully to 30 weeks so that the baby could be delivered appropriately.”
Ms Y continues to refuse fluids. A multidisciplinary team (MDT) is assembled.
Liaison psychiatric team and consultant obstetrician decide there are insufficient grounds for early delivery. Ms Y is told a meeting will discuss her case the next day. She continues to refuse food and fluids.
She continues to refuse food and fluids. Consultant obstetrician X reviews her, explains the implications of her refusal to eat and drink, including cardiac arrest, renal failure and uraemia and says she would be medically unfit to undergo delivery of the baby.
Consultant X tells her the staff may have to apply to the courts if she does not resume eating and drinking.
Ms Y is reviewed by consultant psychiatrist 2. “Ms Y described that she had thought of harming herself . . . When asked if Ms Y had made any previous attempts of self-harm Ms Y indicated that she was planning to hang herself in the toilet beside her room [in her previous accommodation] but that she had been disturbed.”
Following the assessment, consultant psychiatrist 2 records that Ms Y “presented as a significant risk of suicide which was directly related to her unsuccessful efforts to secure an abortion and . . . the ongoing pregnancy was a reminder of Ms Y’s traumatic experience”. It is their view “that the baby should be delivered”.
Ms Y’s respiratory rate increases from 16-18 breaths per minute (bpm) to 24 bpm and later to 28 bpm. Doctors are concerned she could be developing metabolic acidosis, where there is too much acid in body fluids. It can cause coma and death.
A plan to deliver the baby early, on Monday, August 3rd, is made. Ms Y is told. She agrees to eat and drink.
Ms Y is assessed by consultant psychiatrist 3, who believes “if the pregnancy went to term that Ms Y presented as a major suicide risk” and the plan to deliver early was “entirely appropriate”.
Ms Y is reviewed by consultant obstetrician X. A brief discussion takes place about preparing for delivery. “Ms Y’s mood was a little improved.”
Ms Y is visited by hospital’s clinical director and consultant obstetrician X. She is told the hospital is seeking legal advice and that “this might result in changes to the plan”. She becomes very distressed. Ms Y refuses food and fluids and does not communicate with staff.
Ms Y continues to refuse food and fluids. She sees a pastoral care worker who speaks to her about the need to be strong. Ms Y agrees to eat again. Consultant psychiatrist 2 says Ms Y is at “ongoing risk of suicide and she was likely to be at increased risk if she was told that delivery was not going to take place as planned”.
Ms Y tells social worker she does not want to see the baby after it is delivered. All reports needed by hospital’s legal team are submitted. A communication from RIA indicates the principal officer wanted the staff at the hospital to know that if “a request was made for her to travel abroad that the immigration aspects of this would be facilitated by the INIS”.
The HSE applies to the High Court for permission to sedate Ms Y and rehydrate her. She is not represented in court. High Court grants the order but the judge requests Ms Y and the unborn be represented when the case is due back in court on August 5th.
Ms Y is reviewed by obstetrician X and later by consultant psychiatrist 2. She is eating little. She becomes distressed when told the Caesarean section will not take place on Monday as planned, due to legal proceedings. “Ms Y remained adamant she would kill herself if the plan put in place the previous week did not proceed on Monday.”
Her solicitor visits but Ms Y does not engage. She refuses food and fluids after 5pm.
Ms Y declines all food and fluids. MDT meets.
Ms Y has had no fluids for 40 hours. She is met by consultant psychiatrist 4 who records: “Ms Y was an ongoing suicidal risk.” HSE legal team attends High Court. Ms Y agrees to a Caesarean section under anaesthetic the next day. Intramuscular steroids are administered with her consent.
Caesarean section performed. Neonatal team is on standby. Baby boy taken to neonatal unit and into HSE care.
Ms Y is discharged and returns to her accommodation. Baby remains in care of neonatal team and is “making good progress”.