Omagh mum tells inquest her daughter ‘deserved so much better’

AN inquest into the death of an Omagh woman under the care of the Western Trust has concluded that she died from aspiration pneumonitis – a bacterial lung infection.

Tracy Antoinette Butler, aged 35, was born with cerebral palsy, was non-verbal, and had suffered a brain haemorrhage at birth. She passed away on July 18, 2016, at the South West Acute Hospital in Enniskillen.

Delivering the findings, Coroner Anne-Louise Toal expressed her condolences to the Butler family and acknowledged the many questions they had brought to the inquest.

“I hope the findings provide some of the answers you’ve been seeking,” she said.

The inquest, which began in April, heard evidence from family members and medical professionals involved in Ms Butler’s care in the weeks leading up to her death.

Tracy’s mother, Marian Butler, told the court that she had never believed the true cause of her daughter’s death had been fully-established.

“No post-mortem was ever carried out,” she said. “It feels like she was given up on by those who were treating her.”

Mrs Butler also raised serious concerns about a ‘Do Not Resuscitate’ (DNR) order that had been added to her daughter’s medical notes without her knowledge or consent.

During her emotional testimony, she described what she believed were repeated failings in her daughter’s care – from poor communication between hospital staff and the family, to inadequate hygiene and pain management.

“The care was substandard. Hygiene was lacking, and Tracy’s pain wasn’t properly controlled,” she told the court.

Between May 29 and July 18, 2016, Tracy was admitted to hospital six times with complications from sepsis and respiratory failure.

According to her mother, the same issues arose during each admission.

“She was non-verbal and completely dependent on others, yet she was often left in her room unwashed and undressed,” she said.

“Even on her final day, I walked in and found she hadn’t been changed or washed.”

Mrs Butler said she constantly asked basic questions -whether her daughter’s urine had been checked, if bloods had been taken, if her temperature was high, or if infection swabs had been done – but struggled to get answers, especially in the afternoons.

She described Tracy as a spirited and resilient young woman.

“She was a fighter. She strived to have a life. She was loved beyond measure and had a life worth saving,” she said.

“No vulnerable person like Tracy should ever be left to face the same end.”

Concluding her statement, Mrs Butler shared her profound disappointment in the standard of care her daughter received.

“She deserved so much better… better pain relief, better nursing care. I hope now she is in a peaceful place, and that she has earned her wings and her voice.”