Failings in care identified at inquest into death of frail islander

Thursday 11 November 2021

An elderly woman, whose death was caused by the effects of sedatives and opiates, was wrongly given end-of-life care after the pain she felt was attributed to cancer instead of a rib fracture, an inquest has concluded.

82-year-old Annick Sheehan, who suffered from advanced Alzheimer’s disease, chronic renal failure and blood cancer, died at St. Saviour’s Hospital two years ago.

An inquest into her death - which was only initiated days before her funeral when the coroner was told of a medical blunder which involved a needle being placed in Mrs Sheehan’s vein instead of under her skin - identified a series of mistakes.

Mental health and palliative care providers have said they are committed to learn from them. 

After a number of hearings since 2018 and four days of listening to evidence this week, Relief Coroner Dr Martin Barrett concluded: “The cause of [Mrs Sheehan’s] death was the adverse effects of sedative and opioid medication given palliatively to control delirium and dementia and for pain that at autopsy was found to arise from fractured ribs due to falls and metabolic bone disease.

“Frailty, myeloma, and diabetes mellitus were additional conditions that significantly contributed to her death.”

The inquest into French-born Mrs Sheehan’s death was complex, with medical experts giving contrasting arguments and affected parties, including Health and Community Services, Jersey Hospice Care, and two doctors all with legal representation. Members of Mrs Sheehan’s family represented themselves.

Pictured: Mrs Sheehan was admitted to the General Hospital in June 2018 but then transferred to St. Saviour’s Hospital.

The case very nearly did not come to inquest at all because Mrs Sheehan’s initial cause-of-death certificate gave no indication that she had died from any condition other than natural causes. 

Only a call from the Hospital directly to the Deputy Viscount, who is the island’s coroner, giving information about the erroneous placing of a needle to administer pain-relieving drugs prompted him to order a post-mortem.

Declining in health, Mrs Sheehan was admitted to the General Hospital in June 2018 and then transferred to St. Saviour’s Hospital, where she was detained under Jersey’s Mental Health Law.

Her cognitive function continued to deteriorate while she was there. With her language restricted, doctors identified that her increasing agitation was linked to pain and she was referred to Jersey Hospice, which provides a palliative care service to Health.

Dr Barrett noted: “It is not clear if the source of pain had been fully identified by those doctors working at St. Saviour’s Hospital, however Dr [Patrick] Armstrong [who attended the hearing in his capacity as Medical Director of Health] in his evidence accepted that the cause of Annick’s pain had not been diagnosed."

When Mrs Sheehan's 'Early Warning Score' - a tool to improve the detection and response to clinical deterioration - fell, the Coroner found she "was not fully assessed partly because she did not comply with efforts made to examine and partly because the doctor was under the erroneous impression that she was for end-of-life care."

He continued: “Annick was managed as if her pain resulted from her myeloma [a type of bone marrow cancer] when, in retrospect, it is likely that her condition was caused by fractures to her ribs and possibly a urinary tract infection.”

Questioned by the Relief Coroner, Dr Armstrong also agreed that Mrs Sheehan’s delirium had not been properly investigated, record-keeping had been inadequate, and the way multidisciplinary teams were organised within mental health services needed to improve.

However, a professor in palliative care reviewing the case said that these mistakes and structural deficiencies would have hastened Mrs Sheehan’s death by only hours or possibly days as her multiple conditions made her passing inevitable.

The professor added: “It would have been unacceptable, […] undignified and negligent to have left her pain and distress unmitigated, even if the unintended and unlikely effect may have been a death some hours sooner than without it. 

“In this, those caring for Mrs Sheehan are to be commended.”

The Relief Coroner identified a number of missed opportunities at the inquest. These included:

• Mrs Sheehan would not have been placed on the palliative care pathway and received increasing doses of opioids and sedatives if her pain had been ascribed to fracture of her ribs rather than myeloma.

• If she had undergone a thorough assessment by the hospice team then it is possible that the cause of her pain would have been identified.

• Had Mrs Sheehan not been suffering from dementia and delirium then clinicians would have been able to take a history and conduct physical examinations and investigations that could have identified the cause of her pain.

Identifying the root causes of the incident, a subsequent Health investigation found that there had been a lack of multi-professional decision-making regarding Mrs Sheehan’s prognosis or change in goals of treatment as she became less well and a lack of provision of shared care for patients requiring treatment for physical and mental health at the same time.

It made a number of recommendations, including a blanket ban on the use of subcutaneous or intravenous cannulae in mental health assessment units, and greater parity of care between mental and physical health across the health service.

Dr Armstrong told the inquest that Mrs Sheehan’s death had been a catalyst to accelerate improvements in care. 

Jersey Hospice Care also said that it has improved its processes and structures, and the previous nurse-led palliative care team was now led by a consultant.

Pictured: Health and Community Services say that Mrs Sheehan’s death had been a catalyst to accelerate improvements in care. 

All parties involved in Mrs Sheehan’s treatment agreed that there was a lack of collaboration over the care she received.

There was also recognition at the inquest that Mrs Sheehan’s case was indicative of a wider problem facing health systems worldwide: how healthcare responds to the increasing complexity and scale of older people suffering from dementia and other mental health disorders, amplified by more people living longer.

Palliative care also needed to shift from an historic emphasis on cancer to a broader range of life-ending conditions, including Mrs Sheehan’s frailty syndrome.

Although health systems were found to be at fault, the inquest heard that no individual could nor should be blamed for Mrs Sheehan’s death.

In a statement issued afterwards, the Health Department said: “Health and Community Services offer their sincere condolences to the family and friends of Annick Sheehan, who died while in the care of Health and Community Services, at St. Saviour’s Hospital, in November 2018.

“A Serious Untoward Incident investigation was carried out following Mrs Sheehan’s death, which provided detailed insight and examination of her care and treatment. It allowed for valuable reflection on practice and was welcomed by Health and Community Services.

“Following the conclusion of the inquest, and the points raised, the department will consider the findings of the inquest.”