The circumstances pertaining to the death of Frances Sheridan

24-06-2004

The North Eastern Health Board today (24th June 2004) published the report into the circumstances pertaining to the death of Frances Sheridan.

The CEO, Mr. Paul Robinson again wishes to convey his deepest sympathy to the Sheridan family on the death of Frances. The CEO confirmed that a copy of the report has been given to the Sheridan family through their Solicitor.

Following the death of Frances Sheridan on the 1st February 2004, the Assistant Chief Executive Officer for Acute Hospital Services established an independent group to review the circumstances pertaining to her death. This process is in line with the North Eastern Health Board’s Critical Incident Review System which seeks to identify and determine the root causes for an incident, rather than trying to assign blame.

The Terms of Reference of that group were as follows;

• To carry out a review of all factors involved in the death of Frances Sheridan;
• The scope of this review shall cover the period of the child’s first contact with Cavan General Hospital on 7th January 2004 to her untimely death on 1st February 2004;
• The review is to be carried out in accordance with the Board’s guideline – ‘Critical Incident Review’.

Membership of the Review Group

• Dr Brian McDonagh, Consultant Paediatrician (Retired, North Western Health Board) (Chairperson)
• Mr Gerry Clerkin, Risk Advisor, Cavan/Monaghan Hospital Group
• Mr Conor Egleston, A & E Consultant, Our Lady of Lourdes Hospital, Drogheda
• Mr Peter Morrison, Consultant Surgeon, Sligo General Hospital
• Ms Julie Sheridan, Paediatric CNM, Cavan General Hospital

The primary purpose of the review was to ascertain the facts and issues in relation to what happened, the causes and the reasons as to why it happened and the identification of lessons to be learned so that appropriate actions could be planned to minimise the chance of anything similar happening again.

Following release of the report of the post mortem carried out by the State Pathologist, the
Review Team conducted a wide range of interviews including interviews with the Sheridan
family, reviewed all relevant documentation and carried out a site visit. A detailed
chronological review of events was prepared and all data was analysed using the National
Patient Safety Agency “Seven Steps to Patient Safety –Root Cause Analysis Toolkit”
(2004) in order to identify underlying causes. Events were analysed under the following
headings.

• Institutional
• Organisational/Management factors
• Team factors
• Individual (staff) factors
• Task factors
• Patient characteristics

This process identified one care management problem ie ‘a failure to adequately assess
and manage the patient on 30th January, 2004” and a number of contributing factors.
These included inadequacies in systems, an absence of guidelines, a need for enhanced
nursing and clerical staffing and a need for some structural changes in the Accident and
Emergency Department.

Recommendations to deal comprehensively with the weaknesses identified are made
and prioritised in the report. There is a total of twenty two recommendations, of which
eight are high priority and fourteen are medium priority.

Many of the recommendations relate to improved procedures, systems and guidelines. Others have resource implications in relation to both staffing and funding. The Assistant CEO will be meeting urgently with the Hospital Management to implement the recommendations.

Link to Frances Sheridan Report (.pdf file 800Kb approx)