‘Our father goes early to bed, for he is an old man’

Anger is one of the Kübler-Ross stages. You can feel anger towards yourself, towards the dead person, or towards other people. I never felt angry at Bo. It was not his fault that he died. He was the victim of the fumbling of others, which is tragic, for Bo was above all painstaking and conscientious, in all his work and all that he did. He did not take shortcuts and had a deep sense of responsibility and duty. I felt angry towards myself, for my various bad decisions: not to read the instructions on the packet of pills; not to get him to a good hospital while there was still time; not to know about facilities such as private ambulances; and finally to agree to send him to Loughlinstown.

Anger at medical personnel is not uncommon, among the bereaved. I was furious with several doctors. I’ve read studies of grief, so I considered the possibility that this reaction was largely emotional, hysterical. But I am a rational person, and a person who has been trained – by Bo – to think clearly and to rely on evidence. I observed at first hand the way Bo was treated in the hospital, and kept notes even while I was there sitting at his bedside. Failures of care and attention occurred from the beginning, from the moment when the ambulance men had him walk down the drive – I saw the shock and surprise in the ambulance men’s faces when Bo almost collapsed from the effort and pain after the short walk. The confusion as to whether he was in the hospital or not when I arrived there on Monday evening did not inspire confidence in the standards of record-keeping. That the A&E staff did not begin the process of hydration as soon as he was admitted, but left him lying for hours without even a glass of water, was dismaying. The sloppiness about the intravenous drip; the unhelpfulness of individuals and the system in facilitating his transfer to another hospital early in that fateful week; and the horrendous last day when they could not get a bed for him in a hospital with dialysis facilities convinced me that my anger was not irrational. I suspected more and more that a lack of adequate care had been a factor leading to Bo’s death.

Minor administrative errors that I remembered or that came to my attention in the weeks following Bo’s death bolstered my suspicion that there was a general lack of attention to detail in the way the hospital was run. For instance, the unexpected request to cancel the post-mortem examination on Monday 11 November seemed strange, given that the consultant who had recommended the post-mortem had not been aware of this phone call. Who suggested it? Why? The right hand did not seem to know what the left hand was doing. And of course that request begged the question, was there something the hospital wished to hide?

Another cause for uneasiness occurred three weeks after the funeral. I received a bill for Bo’s nights in hospital – in Ireland public patients pay 75 euro per night for a hospital stay in a public hospital if they don’t have a medical. However, patients who are covered by private health insurance don’t pay – the bill is sent directly to the insurance company. Bo had full private insurance. When I telephoned the accounts department querying the bill the official said, ‘Oh, he is registered as a public patient. We didn’t know he was private.’ I recalled then that on the night of Monday, 4 November, when I was at the admissions counter outside A&E, I had said to the official at the desk that Bo had VHI cover (private health insurance). I was told, ‘Oh, that doesn’t matter here.’ If he had been correctly registered would a greater range of hospitals have been available to him, on the last day? Blackrock Clinic, for instance, was much closer than Beaumont. ‘Over to Beaumont in Friday afternoon traffic? It’d be chaos,’ the ambulance man had said to me. But they could not have contacted Blackrock since they believed Bo was not covered for it by insurance. He was incorrectly registered at the point of admission.

I detailed my questions in a long letter to the consultant, which I copied to our GP. The GP responded a month later, sympathetically. The consultant responded promptly and arranged a meeting to deal with my concerns. He was friendly and helpful.

‘I hate the words “What if?” he said. ‘If things had turned out differently, you would not be asking these questions.’

Well, obviously not. He explained Bo’s deterioration as a ‘cascade’. Once it started, with the ingestion of the three pills, it could not be stopped.

My solicitor, who recognised my distress and listened to my doubts, took advice from a barrister who specialises in medical negligence cases. The latter recommended that I commission a report from an expert. I did so – slowly, I must admit. Something held me back, and I did not want to incur large expenses. But on the other hand I wanted to get answers.

In October 2015 the detailed report arrived. I will not reproduce it here. The medical expert found that ‘there was failure to treat Professor Almqvist’. He was critical of the delay in giving fluid resuscitation. ‘A standard procedure would be to give intravenous fluids within one hour to restore his circulating fluid volume, restore his blood pressure, and hopefully restore a good urine output allowing correction of renal failure. His initial litre of fluid was not started until three hours after admission.’

The report found that Bo had suffered from sepsis, which was not identified until after his death. ‘I do not think the source of sepsis could have been identified at the point of admission, but should have been considered as soon as blood results were available. At that point a vigorous search for a source of sepsis should have been initiated and he should have been started on a suitable potent broad spectrum antibiotic pending results of investigations.’

Bo’s organ failure came about as a result of sepsis, which was neither identified nor treated in the hospital.

The broad conclusion was that ‘if optimally managed he on balance of probability would have survived at worst a 20–25% 30-day mortality and a 75%–80% chance of surviving’.

Bo was not ‘optimally managed’. Any fool could see that, and the expert opinion confirmed my impressions. Simple solutions – timely delivery of intravenous fluids, timely administering of an antibiotic – would in all probability have saved his life.

My solicitor said he had never seen such a clear-cut case. ‘It’s black and white. He had an 80 per cent chance of survival.’ He advised suing the hospital. In the event, I decided not to pursue the case. Although I knew my solicitor would only give good advice, I did not want the issue to drag on, and, more than that, I feared the consequences of losing the case. I had no idea how much the case would cost if I lost and had to pay my own legal costs as well as those of the HSE. The solicitor was certain I would win, and pointed out that it would be in the public interest to proceed with the case. But the health service continues to deteriorate, so I am not sure how useful that particular exercise really is.

The HSE could not give me what I want: my husband. Do I blame the hospital for his death? Bo was eighty-two – there seems to be a consensus in Ireland that once you pass eighty you belong to the category ‘old’, the subtext of which can be ‘dispensable’. (‘He is old,’ as one of the doctors I met in Loughlinstown said so ominously.) ‘Old’ is a moveable feast, however, and in Sweden eighty is certainly not considered ‘dispensable’. Of course he was going to die sometime, as we all are. Nothing is truer than the proverb which warns that nobody knows where the sod of his death is. But Bo had recovered from serious illnesses, he was cancer-free, he had a strong constitution, and hoped to live for several more years – he was working on two major books, which he wanted to finish, and he enjoyed life. He had renewed his passport – but he never got to use it. Bo did not have to die on 9 November 2013. He died as if he had been run over by a bus – and the bus was the Irish health system. Had he been in his own country, or in a competent hospital in Ireland, it is more than likely that he would have survived the episode that killed him – 70–80 per cent likely, according to the impartial medical report. As it was, Bo suffered an untimely, painful, and unnecessary death. It is difficult for me not to think of the Irish public health service – sloppy, careless, and ageist – as a murder machine.

In one of his essays Henning Mankell writes about the vak, a patch of thin ice on a frozen lake. If you step on to a vak while skating or walking on the ice, you will sink under the ice and drown in the freezing water. It is almost impossible to rescue a person who is unlucky enough to step on a vak.

Bo stepped on the weak spot in the health service. The thin ice gave way. He was pulled to the bottom, and I could not rescue him.