THE family of an elderly woman who died after suffering two broken legs, following an alleged fall from a wheelchair at a HSE nursing home, have urged people to visit loved ones in care to ensure they are being properly looked after.
Mary Melody suffered two broken femurs in an unwitnessed incident at Raheen Community Hospital, Tuamgraney, County Clare, on July 3, 2021. She died seven days later at University Hospital Limerick (UHL).
Despite the 89-year-old roaring in pain for two days after her alleged fall, the care home staff said they did not call her a doctor because they had checked her and did not see any visible signs of her suffering broken bones.
Staff said they suspected Ms Melody was complaining of pain associated with a pre-existing osteoarthritis in her knees, for which they said they continued to provide her with pain-relief medication.
However, Ms Melody continued to scream in pain, particularly when moved. Staff continued to hoist her from her bed to commode to shower her and lift her in and out of her wheelchair.
One of the care home staff said Ms Melody continued to “shout in pain”, and that, on July 5, Ms Melody was “calling out the Rosary and asking for God to take her, she was in so much pain”.
This staff member shared their concerns with a senior staff member resulting in an ambulance being called to transfer Ms Melody from the care home to UHL, where x-ray scans showed both her femurs were broken.
Due to her age and her serious injuries, Ms Melody was given palliative care at UHL and was pronounced dead there on July 10, seven days after the unwitnessed alleged fall.
Last year, the HSE admitted in an out-of-court personal injuries settlement, taken by Ms Melody’s daughter, Moira Lenihan, that it had breached its duty to provide residential care and treatment to Ms Melody between July 3 and 5, 2021.
Speaking for the first time about their mother’s case, Ms Lenihan and her brother Pat Melody urged others to visit their loved ones in care to ensure they are being properly cared for.
Despite having regularly visited their mother, including on the day of the unwitnessed fall, they say they are still searching for answers about how exactly she came to suffer her broken legs.
“If you have family in care, for God’s sake, go and visit them, because you just don’t know what’s going on after you walk out the door,” said Pat Melody.
“To break your two legs, the big bones in your legs? That’s what we have to put up with now. It’s hard to break your two legs.”
Ms Lenihan said that “there was no reason for all that suffering for Mam, and if staff had contacted the doctor, I would hope, would have avoided all that suffering.”
“I just couldn’t believe that it actually happened. It’s obviously still upsetting us, as it would, and there’s nothing we can do about it,” she said. “To get the HSE to admit failure in Mam’s care is, I suppose, better than nothing.”
Both said they had always assumed a doctor would be notified after a fall of any kind involving residents at a care home.
Commenting on how she felt about her mother’s experience in her last days at care home, Ms Lenihan said: “You wouldn’t do it to an animal. What went on there was ridiculous.”
‘Still searching for answers’
A consultant, involved in Ms Melody’s medical team at UHL, said at Ms Melody’s inquest at Limerick Coroner’s Court in 2024 that she and others in the medical team were agreed that the delay in Ms Melody presenting at UHL warranted an investigation.
The incident was reported to HIQA, the state health watchdog, and the HSE investigated the mater internally.
Pat and Moira said they have heard nothing from HIQA, and feel they are “still searching for answers”.
Ms Melody’s family members told her inquest that they received conflicting reports from staff at the care home about their mother’s injuries, including being told she fell from her chair while exiting a prayer room, and also that she had fell in a sitting room while tea was being served.
Ms Melody’s daughter, Helena Walsh, said it was “very upsetting” for the family to read in the care home’s incident report that their mother’s alleged fall was not witnessed and they “wonder what actually happened to our mother”.
Care home staff said they performed a “full body check” on Ms Melody following her alleged fall, and assisted her back into her chair after she did not complain of pain or appear to have broken bones.
Ms Melody’s son, Seamus Melody, told her inquest that he visited his mother in the care home shortly after the alleged fall and noticed that when a staff member tried to lift her legs back onto the step of the wheelchair “she roared in pain” and sought painkillers.
A staff member stated they simply followed the care home’s policy, which they said was not to call a doctor because Ms Melody was “stable and in no obvious distress”.
A “narrative” verdict of the events was returned at Ms Melody’s inquest, held at Kilmallock courthouse on February 7, 2024.
The Limerick coroner found the cause of death was in line with medical evidence, including two broken femurs, sudden heart and lung failure, heart disease with bleeding, blood clots, and a historic faulty heart valve.
‘Red flags were missed’
An incident report compiled by a senior nurse commissioned by Ms Lenihan’s solicitors stated that, in their view, “red flags were missed” by the care home staff after the alleged fall, “and the change in her clinical picture within 24 hours was not acted upon”.
The report described Ms Melody’s alleged fall and subsequent injuries as being “a seriously significant event”, and added, “the outcome of this fall would have, and unfortunately did, greatly impact her mortality”.
In response to requests for comment, the HSE Mid West said: “We acknowledge the adverse findings in the HSE review of this case, and can confirm that we have implemented the recommendations made to ensure best practice in Raheen CNU, including full medical review by doctor of any resident who falls, a nominated person to communicate with family members after an incident, and comprehensive training in falls management for care staff.”
“It’s a matter of profound regret for HSE Mid West when there is a shortcoming in the care of our patients, and we would like to express our sympathies with Mrs Melody’s relatives on their sad loss.”
HIQA said its chief inspector “does not have a remit to investigate individual deaths in a nursing home, so would not have conducted an investigation into the information that was received”.
“Inspectors review and follow up on any such information received, and can take a number of actions based on this, including conducting an inspection of the facility, and referring the information that we have received to another appropriate agency.”
