AN emotional inquest into the death of a woman at the South West Acute Hospital (SWAH) has heard powerful testimony from her mother, who has stated the true cause of her daughter’s death has never been determined.
Tracy Antoinette Butler, 35, who was born with cerebral palsy, was non-verbal and had suffered a brain haemorrhage at birth, passed away on July 18, 2016, at South West Acute Hospital.
“No post-mortem was ever carried out,” Marian Butler stated. “It feels like she was given up on by those who were treating her.”
The grieving mother also raised serious concerns about a ‘Do Not Resuscitate’ (DNR) order that had been placed on her daughter’s medical notes without her knowledge or consent.
The inquest heard how serious concerns had been raised over the DNR order, which was placed on Tracy’s medical records without the consent of her mother, who was listed as her next of kin.
Ms Butler expressed deep distress over the decision, stating she had never agreed to it and was unaware it had been put in place.
Speaking before the Coroner, she recounted a troubling phone call from a doctor, who informed her about the DNR order.
“I made it clear that I did not consent to this,” she said. “I also told him it was inappropriate to discuss such a serious matter over the phone instead of in person.”
Mrs Butler emphasised that had she known about the order earlier, she would have strongly contested it.
“The doctor felt Tracy was ‘too delicate’ and that this was the best course of action,” she explained.
“But from my perspective, she wasn’t that sick – not enough to justify such a decision.”
The inquest heard that no official notes were recorded from the phone call. Additionally, hospital staff had reportedly spoken to Mrs Butler’s ex-husband about the issue, but when she later visited the hospital, no one was available to discuss it with her.
The inquest examined an independent review of the standard of care Tracy received during her final admission. The review raised concerns over the quality of medical documentation.
“The standard of doctors’ note-taking isn’t always the best – often shorthand and immediate facts,” the inquest heard.
The absence of a post-mortem was also highlighted, with experts stating that without one, it was impossible to determine exactly what had happened in Tracy’s final moments.
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