Paula Breen
By Tom Mooney (in association with The Mary Raftery Journalism Fund)
Paula Breen, a young single mother of a four year old daughter, was rushed to Wexford General Hospital by her sister and her mother on Sunday evening, October 5, 2014.
The 23-year-old had- hours earlier-attempted to take her own life by overdosing on anti-epileptic medication prescribed by her own GP, Lyrica.
Extremely concerned by her condition and her fragile state of mind, her sister Bernadette and mother Angela impressed upon A&E staff about Paula’s need for urgent psychiatric assessment.
Paula was detained overnight for further examination but, following a consultation with a liaison mental health nurse on Monday morning, who ruled that she was medically fit, she was discharged.
Returning to the family home in Ferns in an agitated state, Paula would make two further attempts on her own life before the afternoon was out.
Though the risk of suicide is at its highest in the immediate post-discharge period, many patients like Paula continue to be sent home without proper support to fend for themselves, and many have ended their lives.
Inquests in the South East are awash with claims by bereaved families that victims of suicide were callously discharged from hospitals against their will.
When Paula Breen was born, 13% of the government’s health budget went to mental health services: in 2015 it was just 6.2%.
“In 2010, the year that Wexford and Waterford mental health services amalgamated and all acute beds were moved to Waterford, the suicide rate in Waterford was 11.5 per 100,000, while the rate in Wexford was 11,” said Deputy Mick Wallace in May.
“The following year, the rate in Wexford had almost doubled to 20 per 100,000 and Waterford’s remained steady. Wexford has had roughly double the suicide rate of Waterford ever since.
“New figures from the Central Statistics Office show that Wexford now has the highest suicide rate per capita in the country. It would be hard to find a more striking example of what cuts in this area of the health service can do. They literally kill people.”
Though studies throughout the world confirm that people who self harm are most at risk following discharge, patients in Ireland must leave hospital if they are considered medically fit.
However, being medically fit does not always equate with being psychiatrically fit.
There are known factors which place somebody at a high risk of repeating a suicide bid, and Paula Breen, from the moment she arrived at Wexford Hospital, ticked all the boxes : depression, substance abuse, prior suicide attempts.
Once she was discharged without once being examined by a psychiatrist, the risk of Paula harming herself was a high risk because of (a) the short admission and (b) ineffective care planning.
She was dismissed by our mental health system to tackle her demons alone, with no meaningful attempt to address the adverse events which led to her self harming, and she lost.
Paula was no sooner back in Ferns when she went to the nearby GAA field with a rope: discovered by her siblings, she was talked into returning to their home while frantic telephone calls were made to get her into care.
The psychiatric ward at Waterford Regional Hospital was contacted, but the Breens were told that Paula had to be returned to where she had been discharged, the A&E at Wexford.
Paula, as the family desperately sought help, slipped unnoticed from the house to an old building nearby, and hung herself, four hours after she was deemed at Wexford hospital to be not a suicide risk.
Her story is told here for the first time.
A smoker and a mother by the time she was 19, Paula was on different medication, including Lyrica, Cerazette (for contraceptive effectiveness) and Benzodiazepine (a sedative) intermittently, to offset both anxiety and troubling episodes of epileptic fits, the first of which was in 2012, when she was brought by ambulance to Wexford hospital.
There were other episodes of seizures in the months after, including once in the hospital, and she was medicated with either Lyrica or Lamictal: EEG findings at St Vincent’s Hospital were consistent with a propensity for epileptic attacks.
Paula’s descent into a maelstrom of on and off depression and anxiety was accelerated throughout the years by personal problems.
As a result, Paula visited her GP in Gorey regularly from 2005 to 2014..
Though Paula sought and was offered both psychology and physiotherapy sessions at the Avenue Primary Care Centre in Gorey and St. John’s Hospital in Enniscorthy in the months leading up to her death, she often failed to keep her appointments, sometimes because of the difficulty of arranging transport.
In the ten months counting down to Paula’s death, she made contact with her GP over 20 times, during which she availed of supportive counselling.
There is another side to Paula Breen, which is scarcely touched upon in the thousands of words which document her medical history. She was a daughter, a sister, an aunt and a mother.
“She was amazing,” remarks her sister Bernadette. “She played sports – football and hurling. She could put her hand to anything. She had no fear in her. She loved her family, mam and dad, her brothers and her sisters. Her niece and her nephews were her life.
“She had her little girl at the age of 19, and oh my God she fell in love straight away with her. She was the most amazing mother. They were like best friends.”
The countdown to Paula’s death began a fortnight earlier when a sister detected cut marks on her stomach, but it is unclear if Paula sought medical treatment. There was also a botched attempt to hang herself.
On October 5, shortly after 6 p.m., Paula was discovered slumped over the steering wheel of a truck in the yard of the family home, having overdosed on Lyrica at lunchtime. She was, however, articulate and after some persuasion she agreed to be driven to Wexford hospital.
There, Paula was triaged and she confessed that as well as overdosing on Lyrica, she had also smoked marijuana and heroin, and was suicidal. She was kept in overnight for an electrocardiogram scan.
A psychosocial assessment was requested by her treating medical team on Monday morning and it was completed by the mental health liaison nurse who, in a telephone conversation with the Breen family, was also informed of the two suicide attempts by Paula weeks earlier.
“I stressed to the nurse that Paula was suicidal, that she had taken an overdose the previous day and had attempted suicide in the past,” explains Bernadette.
“The nurse informed me that she would be talking to her superior about Paula and my fears if she was released, but said that she could not see them arriving at a different conclusion about Paula. She explained that Paula would have to give a clean urine sample before they would see her in psychiatry.”
Hospital records describe Paula as ‘extremely agitated…and she had been feeling suicidal.’ Admitted to CCU, Paula was put on a Naloxone infusion and her blood pressure improved.
The mental assessment’s clinical impression was that Paula’s suicide attempt was an “impulsive overdose”. A Sainsbury risk screening (an assessment to encompass risk of suicide) was carried out. It did not indicate a high risk of suicide, and after a telephone discussion between the Mental Health Liaison Nurse and the treating consultant psychiatrist, Paula was discharged.
The nurse believed that Paula was not suffering from a severe mental illness, but that her predominant issue was drug addiction, yet notes of the interview with Paula, seen by The Echo, show that she had admitted that she wanted to kill herself and had intended the overdose to be lethal.
Paula Breen left Wexford Hospital at 2.30 on Monday afternoon, armed with nothing more than a fistful of leaflets with contact numbers for inpatient treatment centres and community based drug initiatives.
“I stressed that Paula was suicidal and I reiterated to the mental health liaison nurse that her form had been very low, that she had been anxious and depressed,” adds Bernadette. “The nurse informed me that if I had money there were other places that I could bring Paula, Newcastle or Wicklow, or I could go private. I explained that we didn’t have private health insurance.
“The nurse explained that they had spoken to Paula about her feelings, but said they were discharging her as she was deemed medically fit. She said she would be giving Paula contact numbers for the FDYS, which would be able to offer support. She added that she would talk to her superior (in Waterford) about my concerns but said she could not see them coming to a different conclusion.
“She explained that my sister would have to give a clean urine sample before they would see her in psychiatry. She couldn’t be assessed until she was clean. After this conversation, I was left feeling hopeless and there was no other option but to have Paula collected from the hospital.”
Paula had in fact been deemed medically fit by the liaison nurse, which is a green light to be discharged immediately.
After the conversation, Bernadette was both despairing and angry. “When I got off the phone I said that this is a load of bullshit. She needs help. How do you say a person is suicidal or not? How can you deem a person not suicidal after hearing and seeing her stomach marks, after she tried to hand herself, and even took overdoses previously.” Paula’s mother drove to Wexford to collect her daughter.
With her extended family in Ferns, Paula’s mental well being continued to deteriorate. She felt that she was not wanted and was anxious to leave, but her family reassured her that they would support her in any way. “She was still very agitated. She didn’t look like somebody who should have been discharged from hospital,” recalls Bernadette.
Later in the afternoon, Paula went out into the family yard for a cigarette, but she removed a rope from a container and rushed to the local GAA pitch. When she was discovered by her brothers, the rope had been thrown over the goal post: this was Paula’s second attempt to try take her own life in less than 24 hours.
“We asked Paula if we could take her back to the A&E in Wexford, but she refused to go. I contacted the psychiatric ward in Waterford Regional Hospital but was told we had to bring her to Wexford,” said Bernadette. “I think I might have been quite rude on the phone and I said ‘thank you for your help’.”
As family members made strident efforts to have Paula hospitalised or seen by a psychiatrist, Paula again left the home, but this time she was not so easily found. Bernadette called 999. “They asked me who did I want and I wasn’t sure whether it was the Gardai or an ambulance, or both.”
When the Gardai arrived Paula was still missing. There was an old and unoccupied house not far from the Breen home, and that is where Gardai located the lifeless body of Paula, having succeeded in taking her own life at the third attempt.
“My family is destroyed, and I believe that if Paula had been given more help and support while she was in hospital, this could have been prevented,” says Bernadette. “We are confused about how we were dismissed by the medical staff given the fact that my sister was obviously showing signs of suicidal tendencies.”
A few weeks after her sister’s death, Bernadette sent a four page correspondence to Wexford Hospital questioning why more pro-active support and help had not been given to Paula. “My family is confused about why our concerns were dismissed by the medical staff, given the fact that my sister was obviously showing signs of suicidal tendencies.”
A review was conducted by Mr. Tim Healy, Assistant Director of Nursing and Dr. Anne Landers, consultant psychiatrist, on behalf of the HSE over a seven month period from April 2015, involving extensive interviews with members of the Breen family, the mental health liaison nurse at Wexford hospital and a consultant psychiatrist.
The HSE issued its findings in November last, and considered the use of a generic contingency plan (to visit a GP) as ‘insufficient’; an individual crisis plan should have been offered to Paula Breen once it was decided that she didn’t need inpatient mental service; no mental health follow up was put in place for Paula even though she had tried to take her own life.
The Breen family is dismissive of the HSE report. “The mental health liaison nurse said she could not assess Paula’s health due to the drugs in her systems, so how can they conclude she had no mental problems while she had drugs in her,” adds Bernadette. “They failed my sister, they failed her daughter, they failed my parents. How many more families have to go through this pain before something is done about it. It’s 2016, and it seems that our country is going backwards in helping mental health patients.”
Paula Breen’s death was subsequently raised with the Department of Health by Dep. Wallace, who asked why patients presenting at Wexford General Hospital with mental health issues, who have also being using substances, are being turned away.
The HSE (South) clarified its position: “ The standard practice for patients presenting with mental health issues who have also been misusing substances is that the assessment would be postponed until the individual is no longer intoxicated and is medically fit to engage in the assessment process. In the interim, the patient remains under the care of the Hospital Emergency Department team.”
At the inquest into Paula’s death, the coroner, Dr Sean Nixon said: ‘Again, when people need help most, there appear to be barriers. I would agree that the resources available to people in distress are not adequate.”
The treatment, or lack of, of Paula is a far cry from the promise of the HSE in 2010 when it promised an investment E18 million to develop community and acute facilities in Wexford and Waterford, with the further aim, to quote Kevin Plunkett, Director of Nursing, HSE Wexford Mental Health Services at the time, to ensure “all our patients and clients have access to appropriate care in an appropriate setting. Services will be available to patients seven days a week, 365 days a year.
At this time, the Wexford-Waterford area had a total of 49 acute beds, 44 in Waterford, and an additional five beds in Newcastle Hospital, which is closer to North Wexford than Waterford. Yet the reality, as outlined by the HSE last month, is just under half of the HSE’s community mental health services provide support seven days a week, and only eight of the 17 mental health areas within its nine community healthcare organisations provide a full weekend support. 37,000 people were referred to the HSE’s 114 community health teams in 2015, and just under a quarter were seen within a week.
Studies continue to show that higher rates of suicide following discharge from general medical wards provide evidence that the transition from in-patient care to home is a stressful one. Such was the case with Paula Breen, and the HSE should have been aware that suicidal intent remains fluid in the aftermath of self-harming. It should be best practice that assessing the risk of suicide with a patient openly expressing suicidal thoughts – irrespective of whether they are deemed medically fit or not – is crucial toward preventing their death.
“Since that day on October 6, 2014, we have been asking ourselves why did this happen,” says Bernadette. “What more did Paula have to do to get help? She went into the hospital after taking an overdose, with self harm marks on her arms and her stomach, and was hoping that what she took, even according to the hospital records, was enough to kill her, yet she was discharged as medically fit, and not suicidal.
“A patient who presents herself with suicidal ideation, and previous self farm and in a state of mental distress, is sent home with leaflets. As stated in the Mental Health Act 2001, failure to admit such a patient to an approved centre would be likely to lead to a serious deterioration in her condition. This was the case with my sister, Paula. Less than four hours from returning from Wexford hospital, she was found dead by her two brothers.”
