The death of Savita Halappanavar in an Irish hospital last October made global headlines and shone a critical light on standards of treatment in Irish healthcare. Yet in many ways, the equally tragic but altogether more ordinary death of Peter Acton, a 61-year-old painter from Clondalkin, in Tallaght hospital some years earlier, is more instructive for people who have concerns about the treatment of family members in Irish hospitals.
The circumstances that led to Ms Halappanavar’s death were extremely rare, but there was nothing particularly out-of-the-ordinary about Mr Acton’s case, when he first presented at Tallaght in September 2005. He was diagnosed with pneumonia, sent home, readmitted and died days later, in part because he was left to “dehydrate to death”, in his family’s words.
Infuriated
In such circumstances, many families accept the reassurances of the medical personnel that they had done their best. They factor in age and reason that their deceased had had "a good innings". They think back to previous illnesses – Mr Acton had suffered oesophageal cancer but recovered – and imagine that in some way these played a part in the death.
Not the Actons.
Infuriated with the failings in his treatment – his death was preceded by a slow and exceedingly painful decline, witnessed by his loved ones, as staff failed to provide hydration – they sought answers.
His original death certificate wrongly gave cancer as a cause of death, and it took three attempts and several years to get that corrected. Contact with the hospital’s advocacy board led to a meeting with his consultant, who freely admitted there had been a “catastrophic cascade of errors” in the treatment provided.
However, efforts to have a proper investigation came to nothing. The hospital refused, while the Health Information and Quality Authority and the Medical Council said it wasn't in their remit to investigate a hospital. Records went missing, staff could not be traced and remain largely unidentified, and his death was not reported by the hospital to the coroner.
The family took proceedings, to which the hospital filed a full defence. Sinn Féin health spokesman Caoimhghín Ó Caoláin helped advance their cause and their solicitor, Pat O’Neill, wrote to the Attorney General and the Dublin City Coroner seeking an inquest.
Earlier this year, more than seven years after Mr Acton's death, the coroner, Dr Brian Farrell, agreed to hold an inquest. This took place in May and returned a narrative verdict. Dr Farrell said he was precluded by law from making a finding of unlawful death.
The proceedings reached the High Court yesterday, where the hospital completed its inevitable capitulation with an unreserved apology for Mr Acton’s “untimely” death and the payment of €320,000 in damages to his widow, Lydia.
Negligence
"We also fully acknowledge that Mr Acton's death was due to negligence and in particular the failure to properly address the severity of his condition at the time, combined with the failure to respond to Mr Acton's deteriorating clinical situation thereafter," it said in a short statement.
Just as University Hospital Galway has been keen to emphasise the changes it has made since Ms Halappanavar’s death, Tallaght hospital yesterday stressed it had put in place protocols to prevent a recurrence of the circumstances that led to Mr Acton’s death. Hospitals like to talk about systems, which can be changed, rather than staff. Management and governance at Tallaght have been shaken up since 2005 and it is fair to say the hospital is a better-performing institution than it was.
For the Actons, the unanswered questions remain. They estimate that about 25 staff involved in their father’s care remain unidentified or are said to be uncontactable. Gardaí are aware of the case but are waiting for other investigations to play out before deciding on a course of action. The family want a commission of investigation to examine Mr Acton’s death. Almost eight years on, the fight goes on.
