Mayo son believes father's death could have been prevented

The son of a Lahardane man who drowned shortly after walking out of Mayo University Hospital believes steps could have been taken to prevent him leaving despite comments to the contrary by the coroner for Mayo.

A verdict of accidental death was recorded into the death of Patrick Rowland of Tobernaveen, Lahardane with Patrick O'Connor, the coroner for Mayo making a number of recommendations for Mayo University Hospital (MUH) and Mayo County Council to follow which may prevent further tragedies.

The recommendations in relation to MUH included training being given to all staff on how to deal with patients who express a desire to self discharge and formal guidelines for staff to report and record patients who are at risk of absconding to ensure such documents form part of the medical record of a patient.

Mr Rowland (69) left the hospital in the early hours of January 17, 2023 shortly after he was given a bed in Ward B following 42 hours on a trolley in the Emergency Department after he was admitted suffering from pneumonia. His body was discovered on January 19 in the Castlebar River and the post mortem found he died as a result of asphyxia due to drowning.

Mr Rowland had expressed a desire to leave the hospital during his stay and security guards had to bring him back to the Emergency Department after he had earlier attempted to leave.

31 witnesses

His inquest, which took place over three days in June in Swinford Courthouse, heard evidence from 31 witnesses including members of the Rowland family and staff from MUH.

In delivering his verdict in Swinford Courthouse yesterday (Monday) afternoon, Mr O'Connor commented that the hospital was not a prison and it was Mr Rowland's own choice to leave the hospital.

Speaking following the inquest, Cormac Rowland, son of the deceased, welcomed the recommendations outlined by the coroner but did not accept his father was capable of making the decision to leave on his own accord.

“He wasn't in the fullness of his mind. They [hospital] did not accept that ... but I have known my father since the day I was born. When I went in that night everyone could see how out of kilter he was,” he said, adding that the policy of the hospital to deal with patients who want to leave is too reactive.

“When someone leaves the hospital there are a number of steps to follow. What we are saying is an absconding policy needs to be proactive. If somebody is hitting markers or articulating they want to leave, then that has to be a red light and you have to be in a situation where that gets passed on from one part of the hospital to the other.

“Essentially the crux of all this is the lack of communication from one place to the next and my father slipped through the cracks and ultimately we have to bear that burden and carry that loss,” he said.

When Mr O'Connor recorded the verdict of accidental death, there was visible upset amongst some members of the Rowland family. Roger Murray, senior counsel for the Rowland Family said that while they accept that on 'the balance of probabilities' what caused Mr Rowland to enter the water was likely an accidental event, the key question is how did he end up in that position.

“The family's position is and this was established clearly through the evidence that key clinical and non-clinical information was not given to the staff on Ward B on handover when Patrick Rowland left the hospital on the night in question. It is the family's steadfast position that had that information been given that Patrick would not have left the hospital,” he said following the inquest verdict.

“The nurse who gave evidence said that had the full picture been known to the staff at Ward B certain safety netting would have been put in place and Patrick would have been accompanied and other mitigating factors put in place.

“The family's position is had he been where they thought he was and that was tucked up in bed with the side rails up on the bed and had the full facts been transmitted to the hospital staff on the night in question, Patrick would never have been next, nigh or near a river and this calamity would not have befallen him.”

Mayo Coroner Pat O'Connor recorded a verdict of accidental death

Civil proceedings

Mr Murray also confirmed that the family are contemplating taken civil proceedings against the HSE in relation to the circumstances surrounding the death of Patrick

The inquest heard evidence that Mr Rowland had been in a confused state after he was admitted to the hospital on the morning of January 15, 2023.

He was being treated for sepsis and on the evening of January 16, he was contacting different family members he wanted to go home and to collect him. His wife Louisa told the inquest that at one stage he told her that the nurses were having a party and she felt he was 'raving'.

His son Cormac went into the hospital at 10.30pm and Mr Rowland was eventually given a bed on Ward B at 12.20am on January 17. However, approximately 30 minutes later he left the hospital and phoned his son Cormac at 1.13am telling him he was at the TF Royal Hotel across from the hospital and he was going home.

At 1.32am, he told his father he would meet him at Market Square in Castlebar but when he arrived he was unable to locate him. An extensive search involving the emergency services was unable to locate Mr Rowland around Castlebar.

CCTV footage from the hospital showed Mr Rowland leaving the hospital in his pyjamas at approximately 1.10am via a service entrance in the basement of the hospital. CCTV footage from around the town which showed Mr Rowland on Ellison Street at 1.26am. The coverage on Market Square shows him walking towards Newport Road at 1.30am and the last sighting was at 1.32am from the Castlebar Educate Together National School building close to the bridge at the town river. His slipper was later found close to the bottom of the bridge along the riverbank on the Newport Road.

Difficult to comprehend

Cormac Rowland described his father as his hero and the circumstances of his death are difficult to comprehend for the family.

“For a man who adhered to the system as resolutely as he did the way he met his end caused us great distress and an awful lot of angst. It is something we live with every day on a daily basis,” he said.

Mr O'Connor expressed sympathy to the family of Mr Rowland on their loss and accepted the bone fides that they wished to highlight the circumstances that lead to his death.

Other recommendations he made in relation to MUH were that hospital guidelines about sepsis and the recording of Early Warning Scores should be adhered to and guidelines be introduced with regard to monitoring patients to include the length of time on trolley, age and medical conditions.

Mr O'Connor also recommended that Mayo County Council place appropriate barriers on the river closer to the town of Castlebar to prevent people who fall in from being carried further down the river.

Mr O'Connor commended An Garda Síochána and the emergency services and volunteers who took part in the search for Mr Rowland while Mr Luán Ó Braonáin, senior counsel for the staff of MUH extended his sympathy to the Rowland family.