Jury in choking case seeks alert review at hospital
A JURY has called for a review of the emergency alert procedures of a leading psychiatric hospital after a patient choked to death at dinner.
William Wilson, a patient at St Brendan's Hospital, Grange-gorman, Dublin 7, suffered a choking episode on December 23, 2008.
Dublin City Coroner's Court heard Mr Wilson presented to clinical nurse manager Liam Gleeson at the clinic room at about 5.25pm in distress following his evening meal.
The 58-year old, who had a history of schizophrenia, was trying to speak but was unable to do so and was very agitated.
He had come from the dining room and was not in distress leaving it, the inquest heard.
Mr Gleeson brought Mr Wilson to his room and was "inching him to his bed" when he collapsed "face down".
The alarm was raised and nurse Pat Scott removed masticated potato from Mr Wilson's mouth. CPR was started within seconds. Mr Wilson died at St Vincent's Hospital on Christmas Eve 2008 after suffering irreparable brain damage due to a cardiac arrest due to a choking episode.
Questioned by a brother of the patient, Alan Wilson, from the body of the court, as to whether the time to seek assistance (from other staff members) was when the 58-year-old presented in an agitated state, Mr Gleeson told the inquest he thought it was safer to get Mr Wilson to his bed and examine him further. He said he saw no signs he was choking.
Another brother, Louis Wilson, who referred to St Brendan's as a "Victorian institution", expressed concern there was a 17-minute gap between the doctor being called and his arrival.
Dublin City Coroner's Court heard the duty doctor at the hospital arrived at the scene at 5.50pm, 25 minutes after Mr Wilson presented at the clinic room in distress. The inquest did not establish what time the doctor was contacted at.
A jury of six men and two women returned a verdict of death by misadventure under the direction of coroner Dr Brian Farrell and said the hospital should review the alert procedures in emergency situations.
The inquest heard there was an alarm system in place, but that Mr Gleeson did not press his alarm. Nurse Scott was on the scene within seconds and that was probably the reason he did not activate the alarm, Mr Gleeson said.
"This is a sudden unexpected death due to a choking incident," said the coroner.