The Broken Body
More than two months after their mother died, the family of Maureen McGinley received news that was to change their lives forever in a meeting with her GP.
Her youngest daughter Tina recalls: “I just walked around in a daze for hours, I couldn’t believe what I had just heard.”
The doctor had just told them that her 78-year-old mother’s body had suffered more than 30 broken bones - after she died.
The cause of the fractures was unknown.
She said: “I was devastated and completely shocked, I just couldn’t understand how that could happen and still cannot understand it.”
Fifteen years of campaigning later and in spite of a string of official inquiries, the family still does not know how the injuries were caused.
The only thing that is known for sure is that the fractures happened at some point between her death from pneumonia at Altnagelvin Hospital in Londonderry and her body arriving for a post-mortem examination in Belfast.
Investigations by health trust officials, the coroner and the police were unable to point to any definitive causes.
The case was also taken up by the Northern Ireland Ombudsman – the public services’ watchdog - and the full details of his findings have never been made public, until now.
BBC News NI has obtained a copy of the final report, which raises serious questions about the hospital’s investigation following Maureen McGinley’s death.
The family have not given up trying to get answers to their questions.
'Mammy'
Maureen Early was born in County Tyrone in 1928.
She spent most of her life in the town of Strabane, perched on the border with the Republic of Ireland.
She was married to her husband Jimmy McGinley for more than 40 years and they had eight children and a cherished group of grandchildren.
The McGinley home became known as a place where the kettle was always on and sandwiches were at the ready.
While raising her family, Maureen worked in an old flax-spinning factory for over half of her life.
The annual summer holiday for the family was to Killarney over the Irish border.
Indeed, Maureen was only on a plane once in her life.
When she was in her mid-70s, after a lifetime of playing bingo in local halls, she decided to expand her horizons and took a flight to the bright lights of Blackpool.
Her husband Jimmy died of a heart attack in 1996 and soon after, their youngest daughter Tina moved in with her mother.
Tina still lives in the house with her own family.
She said: “There are days you look around the house and you just expect to see her sitting with a cup of tea, having a laugh.
“The house feels empty now because I didn’t just lose my mother, I lost my best friend as well."
The family home is a corner house in a cul-de-sac and it remains virtually untouched since the day Maureen left it.
The living room is adorned with religious pictures as well as photos of her children and grandchildren.
Maureen's eldest daughter Tish always sits in her mother's favourite chair when she visits her old home.
“She loved looking out the window, with her dog on her lap and just watching the world go by. It’s her chair and always will be,” she told me.
“I just like sitting in it, it makes me feel close to her.”
Even after Maureen died, the McGinley house was still a place where friends and relations would stop in unannounced.
Her middle daughter Anna recalls: “Mammy was a Strabane woman through and through, she taught us you never let people leave your house on an empty stomach.
“She was just a wee pensioner that always had time for everyone and that’s what makes what happened to her in the end even more awful.”
The tragic story of what happened to Maureen McGinley starts in the early hours of Sunday 31 December in 2006.
She fell from her bed at about 04:00 and was taken the 14-mile journey from her home to Altnagelvin Hospital in Londonderry by ambulance.
Altnagelvin Hospital, Londonderry
Altnagelvin Hospital, Londonderry
She had an X-ray when she arrived in hospital but no broken bones were recorded.
After a few days on the hospital ward she developed pneumonia, had an intracranial bleed and at 18:30 on Wednesday 3 January 2007, Maureen passed away.
Her middle daughter, Anna, recalls hearing the news of her mother’s death.
She said: “When mammy was in hospital we had all taken turns to be with her, she was never left alone, but with the pneumonia she went downhill very quickly.
“We were obviously all devastated when she died, but we had no idea of what was to come.”
Her body was transferred to the hospital mortuary and would remain there until the morning of Friday 5 January.
A decision had been made by the hospital that as Maureen had been admitted following a fall, her case should be reported to the coroner and a post-mortem examination was to be carried out to determine the cause of death.
At 06:00 on Friday 5 January, funeral home staff collected Maureen's body from the hospital to take her to Forster Green mortuary in Belfast more than 75 miles away, on behalf of the coroner.
The post-mortem examination was scheduled for 08:30.
Three days later Maureen was buried alongside her husband in Strabane.
In March, while the family were still coming to terms with her loss, Maureen’s GP received a copy of the post-mortem report and asked to meet them.
Tina and her older brother Martin could not have imagined what the doctor would tell them when they met to discuss the report.
Tina said: “I just remember mammy’s GP saying: ‘I’m not sure how to tell you this but your mother had a large number broken bones after death.
“After the meeting I remember walking for two miles in a daze.
“When I stopped I didn’t even know where I was, but all I could think about was how am I going to tell the rest of the family?”
After leaving the GP’s surgery, her brother Martin visited his mother’s grave.
He said: “I had to tell the brothers and I remember going to her grave, just almost to talk to her.”
Martin McGinley promised his mother that the family would do everything they could to get to the truth.
Tina took on the responsibility of telling her older sisters.
Anna says she can still clearly remember hearing the news.
She said: “I just burst out crying, to hear all this after mammy was dead and buried, it was gut wrenching.
“It just stopped the bereavement process in its tracks and we’ve been stuck in limbo ever since.”
Post Mortem
The post-mortem examination was carried out by Dr Alistair Bentley, who was then Northern Ireland’s deputy state pathologist.
He found that Maureen’s body had 34 unexplained fractures to her chest and a broken bone in her neck.
Dr Bentley confirmed there were no obvious rib fractures on the X-rays taken when she was admitted to hospital.
He noted there was only a small amount of bruising associated with two of the 34 rib fractures, “strongly suggesting that the vast majority of them were sustained after death, probably as the body was being moved”.
Dr Bentley said there was a possibility that the neck fracture could have been caused by Maureen’s fall from bed or because of the positioning of the body during the post-mortem procedure.
He noted that Maureen had osteoporosis, which can result in brittle bones and can sometimes mean bones can be “easily fractured”.
But in correspondence about Maureen’s case to the medical director of the Western Trust on 22 March 2007, Dr Bentley said that such a large number of post-mortem fractures was “extremely unusual”.
He also recorded that no resuscitation had been attempted and that the bone fractures were not consistent with this as a possible cause.
Dr Bentley stated: “Very occasionally one or two post-mortem rib fractures may be identified at autopsy, particularly in the elderly, however a large number of post-mortem fractures is extremely unusual, even in the presence of marked osteoporosis.
“This would strongly suggest that at some point during the handling or moving of the body some considerable force had been applied to the chest, however there are no specific features to indicate exactly how they were sustained.”
Dr Bentley did not think this necessarily meant her body was subject to “rough handling”.
He said that there was the “possibility” that they could have been caused by straps used by the undertaker when transporting the body from the hospital mortuary.
But he also thought the fractures could have occurred when Maureen’s body was being moved from the ward to the mortuary or while in the mortuary.
He acknowledged it would be difficult to find out at what point in the chain of post-mortem events the fractures were sustained.
Some years later, during a separate investigation, Dr Bentley was asked if he had ever seen a similar case of such a large number of rib fractures
He had.
Those cases had been victims of trauma caused by road traffic crashes or crushing incidents - in one case, he gave the example of a building collapsing on a person – but he said all of these had been sustained before death.
Maureen’s youngest daughter Tina still finds it difficult to contemplate the extent of her mother’s injuries.
“That is an awful lot of broken bones for one wee woman’s body to sustain.
“Our mother was only a small wee thing, it’s just awful, it’s unthinkable.”
The Western Health and Social Care Trust, which runs Altnagelvin Hospital, said it only became aware of the fractures when it was contacted by the family on 19 March 2007 after their meeting with the GP.
The trust said it began an internal investigation on the same day, which was completed within a week and resulted in a three-page report.
As part of this investigation, the McGinley family had one meeting with hospital staff.
Just minutes before it began, a representative from the Western Trust phoned the local funeral directors.
The man who took the call was Jude Maguire, manager of the undertakers in Strabane.
During that call, Mr Maguire says the trust indicated to him that a post-mortem investigation had found that his staff were responsible for the post-mortem injuries to Maureen’s body.
“I remember that call very well and I remember being very unhappy about it.
“I felt like we were being blamed for something we were innocent of."
The trust’s internal investigation had leaned heavily on the comment made by the deputy state pathologist that there was “the possibility” that injuries could have been caused by straps placed on the body by the undertaker.
Referencing Dr Bentley’s comments, the trust’s investigation concluded: “Often undertakers transport a body on a stretcher with the body secured by means of adjustable straps, it is possible that if the straps across the chest had been applied tightly, it could cause these injuries.”
A copy of the trust’s report was sent to the coroner’s office and forwarded to the state pathologist.
But the state pathologist wasn’t happy with the trust’s conclusion.
In correspondence from 9 May 2007, the state pathologist stated:
“I am concerned that the internal hospital investigation attempts to exonerate the hospital in respect of the causation of the rib fractures.
“Quite clearly they could have occurred whilst the patient was being moved from the ward to the mortuary or indeed in the mortuary prior to transportation of the body to Belfast City Mortuary.”
Jude Maguire felt he and his firm were vindicated by the post-mortem report.
“It was clear when I read the report, there was no such conclusion that it was our fault. But it was like we were being made the scapegoats anyway.”
The Campaign
The trust's internal investigation and report was also far from satisfactory from the family's point of view.
Her daughter, Anna, said: “It all just seemed to be finished very quickly and it looked like blame was being put on the undertaker without acknowledging it could have happened at the hospital and there was no definite conclusion.”
She added: “After that report, communication within the trust was poor, so we started our campaign.”
Fifteen years of campaigning have provided the McGinley family with a scrapbook filled with newspaper clippings, but not many answers.
Tina said she started keeping the clippings as a way of remembering everything they’ve been through.
“It’s hard to believe that after all these years we’re no closer to the truth.”
In the weeks and months following their mother’s death, the McGinley family held a number of protests outside the hospital where she died.
As their campaign generated publicity, they began to receive a number of anonymous messages and “tip-offs” from alleged whistle-blowers.
They were told stories about what might have happened their mother – from her body falling off a hospital gurney while being raced down a hallway, to boxes being placed on top of her body.
Maureen’s daughter, Anna, said hearing those stories re-traumatised her family.
She said: “Some of the things we had to listen to were just awful and you then had to try to go to bed and sleep with this on your mind.”
The Ombudsman
Six years into their campaign, the McGinley family called for an investigation by the public service watchdog.
The Northern Ireland Public Service Ombudsman is the last stop for families who feel they have been failed by public bodies, such as health trusts.
The ombudsman will only take on a case when all other avenues have been exhausted.
The McGinley family took their complaint to the Northern Ireland Public Service Ombudsman in 2013 and the report was finished in 2017.
The ombudsman who investigated the family’s complaint was Dr Tom Frawley.
Dr Tom Frawley
Dr Tom Frawley
He has since retired and the investigation into the McGinley case was one of his final reports.
Dr Frawley’s report was an extensive examination of all the possible causes of Maureen McGinley’s post-mortem fractures.
It also reached damning conclusions about how the Western Trust undertook its “wholly inadequate” investigation into the McGinley case.
Specifically, Dr Frawley examined the trust’s conclusion that the injuries were caused by straps applied by the undertaker.
His findings – seen by BBC News NI – raised serious questions about the health trust’s explanation of how Maureen’s injuries were caused and how it was reached.
The ombudsman interviewed deputy state pathologist Dr Alastair Bentley as part of his investigation - he reiterated that he had raised the straps being used by the undertaker as only one possible explanation.
In his report, the ombudsman was also critical of how the trust had acted towards the undertaker.
The ombudsman said the communication from the trust to the funeral director that the post-mortem report had stated the injuries were his was fault, was simply “wrong”.
One of the ombudsman’s independent expert pathologists said that the number of fractures was far greater than what one would expect in such a standard post-mortem procedure as a tight application of straps around a chest.
The funeral director, Jude Maguire, says the ombudsman’s conclusions underlined what he already knew.
He said: “After the ombudsman’s report I did feel relieved that we were not being blamed and we were exonerated, but I still felt bad for the family.
“It hasn’t been a satisfactory outcome for them, because 15 years on they’re still trying to get answers, it’s been a complete nightmare for them.”
The ombudsman's report also said the trust had “failed to investigate whether anything unusual or untoward had happened to Mrs McGinley’s body while it was in the care of the trust”.
And it raised a number of other questions about the trust’s investigation into the case.
This included inconsistencies in information provided by the trust around the availability of CCTV footage.
During the McGinley family’s only meeting with the trust in March 2007 about its internal investigation, they discovered that their mother’s body had been transferred to the mortuary through a tunnel-shaped corridor.
The family say during the meeting they asked the trust if the tunnel was fitted with CCTV. The family claimed they were told by the trust that footage had been “burned”.
But the McGinleys say that they were subsequently informed by the trust that the cameras had in fact not been working at the time their mother’s body was transported through the tunnel.
During the ombudsman’s investigation, there was a third CCTV explanation – the trust said that there were no CCTV cameras in the tunnel at the time Maureen’s body was being transferred.
However, when presented with the ombudsman’s draft report, the trust said they had provided “erroneous information”.
The trust subsequently confirmed to the ombudsman that there were in fact three CCTV cameras in operation on the route to the mortuary at the relevant time.
The trust also informed the ombudsman that the video recording system at the hospital in 2007 involved the use of 31 video cassette tapes.
The tape was changed each day and kept until the 31 tapes were used - they were then reused and recorded over.
The trust said their investigation started on 20 March 2007 and because the relevant tape was from early January, it had already been recorded over.
As part of his report, the ombudsman reminded the trust that inaccurate information about the CCTV had been provided on a number occasions and with an issue of such importance it was of “serious concern”.
Maureen’s daughter, Tina, says her family still cannot understand the confusion around the CCTV.
She said: “It just doesn’t add up. How can there be so many different versions of what was happening with the CCTV, only one of them can be true?
“All we wanted was help in getting answers as to what happened to our mother’s body and that footage could have been really important in that, but we’ll never know now.”
The ombudsman’s report ultimately found there were a number of possible causes of Maureen’s post-mortem fractures, but the investigation was unable to establish the exact cause or when the injuries occurred.
The investigation concluded that the “most likely” explanation was that Maureen’s bones could have accidentally been fractured during “last offices”.
This is the process that occurs in hospital in the aftermath of a patient’s death. It involves staff preparing the body for relatives and can include straightening, dressing and if necessary washing the body.
But the trust didn’t keep sufficient records around the last offices process and the ombudsman said this made it impossible to find out exactly what happened then.
The ombudsman also said “regrettably” the trust failed to conduct interviews with staff involved in the handling of Maureen’s body.
In his investigation, the ombudsman also revealed that the police had been involved in the McGinley case.
In April 2007, the coroner asked the Police Service of Northern Ireland (PSNI) to interview a number of potential witnesses.
However, the police's investigation was also unable to reach any definitive conclusions in relation to the cause of the fractures.
In a letter from the police to the coroner, they outlined how a hospital porter told them they had overheard another porter claim Maureen’s injuries were caused by accident.
They claimed that the trolley her body was on either had a faulty break or fell off the trolley.
But the ombudsman wasn’t able to establish the truth of these claims.
Commenting on the trust's overall investigation into the McGinley case, Dr Frawley stated:
“It is impossible to understand why the trust, one of whose stated aims is to learn lessons from complaints, did not adequately investigate this serious adverse incident which was also attracting significant public attention and indeed serious adverse comment that was having serious implications for the public standing of the trust.”
The Apology
Maureen’s daughter said that the ombudsman’s report made for difficult reading in parts.
“There were things in there that we were hearing for the first time, why did it take 10 years and an ombudsman’s report for some of that stuff to surface?
“And the report proved that we weren’t given a proper investigation by the trust in the aftermath of what happened, I believe it is the main reason we have been left with no answers for 15 years.”
Following the ombudsman’s investigation, the Western Trust extended its condolences and sympathies to the McGinley family.
It said it had been open and honest with the family at all times and was always committed to ensuring that their concerns would be “fully investigated”.
Concluding its evidence to the ombudsman, the trust also stated: “This is a case where something occurred which caused the fractures to Mrs McGinley post mortem and for different periods of the time being investigated the body was in the care and the supervision of the trust, the undertaker and the coroner.
“In the trust’s view there is no definitive evidence to prove, or even strongly suggest, that the fractures were caused whilst the body was in the care of the trust and that it is extremely difficult for the trust to provide a definitive explanation as to how the injuries to Mrs McGinley were caused.”
Fifteen years after Maureen McGinley’s death, BBC News NI asked the Western Trust if it acknowledged that it was possible that the fractures could have occurred in the grounds of Altnagelvin Hospital.
In a statement the trust said: “We reiterate our sincerest apologies to the McGinley family for the distress experienced as a result of the trust’s failures in the investigation of the critical incident review that it instigated in March 2007 when we learned of the injuries sustained to Mrs McGinley post mortem.
“We fully accepted the findings of Dr Frawley’s report, and are committed to the implementing the learning and recommendations from the report.”
Dignity
Joe McCrisken has been the coroner for Northern Ireland since 2016.
There are more than 16,000 deaths in Northern Ireland every year and about 4,000 of these are reported to the coroner.
Mr McCrisken said the issue of how bodies are treated is an important one.
“If I’ve ordered a post-mortem, this will involve a head-to-toe examination of the body, every bruise, abrasion and scratch will be recorded by the pathologist.
"It is crucial for the role that the pathologist has to perform that the body arrives intact, as well as my role in my responsibility to give answers to families as to what to happened their loved one.
“After a referral, as it is the coroner that takes possession of someone’s relative, it’s important that body is treated with dignity and respect and I take that responsibility very seriously.”
Mr McCrisken recognises the distress that the McGinley family continues to experience.
“I completely understand why the McGinley family feel like they do, that they can’t move on or grieve properly because there are still answers outstanding to the questions they have."
The issue of how bodies are safeguarded after death is currently the subject of a wide-ranging national public inquiry in England.
The inquiry was launched after it emerged that a hospital electrician accessed mortuaries and sexually abused at least 100 bodies in two Kent hospital morgues over 12 years.
David Fuller
David Fuller
David Fuller, 67, filmed himself abusing the bodies.
While the first stage of the inquiry will focus largely on how this was allowed to happen in these morgues, the second part has a much wider remit.
It will look for lessons to be learned across the NHS, but also local authority mortuaries and privately-run funeral directors.
The inquiry has been launched to look at the offences and their "national implications".
Specifically it will try to understand how these offences took place without detection and look at who has access to things like CCTV and documentation in these settings.
The inquiry is chaired by Sir Jonathon Michael and the full terms of reference are due to be announced
'We want honesty'
While searching for answers themselves, the McGinleys threw their support behind another family’s campaign for transparency in the health service.
In 2018, they went door to door in Strabane to raise awareness about the case of nine-year-old Raychel Ferguson.
Raychel Ferguson died at the Royal Victoria Hospital for Sick Children in June 2001
Raychel Ferguson died at the Royal Victoria Hospital for Sick Children in June 2001
Raychel was one of five children who died in Northern Ireland's hospitals as a result of a medical condition called hyponatraemia that occurs when there is a shortage of sodium in the bloodstream.
Their deaths led to the 14-year-long Hyponatraemia Inquiry, the longest running public inquiry in UK history.
It found that four of the children’s deaths, including Raychel’s, were avoidable and was highly critical of a “self-regulating and unmonitored” health service.
Adam Strain, Raychel Ferguson, Claire Roberts and Conor Mitchell. Lucy Crawford's family chose not to release a photograph
Adam Strain, Raychel Ferguson, Claire Roberts and Conor Mitchell. Lucy Crawford's family chose not to release a photograph
Among the inquiry's 96 recommendations, was that a statutory duty of candour should be introduced “as a matter of urgency”.
This would mean that, under law, every healthcare organisation and everyone working for them must be open and honest with patients and the public.
Any potential legislation on a duty of candour is unlikely to be considered until after the Northern Ireland Assembly elections in May 2022.
In a statement the Department of Health said:
“The Department is unable to comment on individual cases. Work continues to implement the recommendations from the Inquiry into Hyponatraemia Related Deaths, which include a statutory duty of candour and a 'being open' culture within the health service.”
Maureen’s middle daughter Anna said: “It’s not a big ask to be told what happened to your loved one once they go into hospital - all people want is honesty.
“In the case of our mother, if we had have been told what happened was some sort of an accident, for example, obviously we wouldn’t have been happy about it, but we would have accepted it.”
January 2022 marks the 15th anniversary of Maureen’s death.
Walking from the church to the graveyard, Maureen’s oldest daughter, Tish, said: “We come here quite regularly just to let her know that we’re all still missing her big time.
“But we know she can’t rest in peace until we all know the truth of what happened.”
As Tina laid fresh flowers on her mother’s grave, she said: “I just like to sit at the side of the grave to talk to her, to let her know that we’ll fight on for answers and we won’t give up.“
The family clings to the hope that someone will yet come forward with information.
Anna said: “I just hope people can have a heart if they know something, everyone has a mother and how would they would feel if they were us.
“We’ve lost a brother and a sister since mammy died. When our sister was dying in hospital she asked for her body not to be left on its own. Our brother had cancer and decided to die at home rather than go into hospital."
She added: “We’ve faced an attitude down the years from different people kind of saying: ‘Well at least your mother was dead when it happened, she felt no pain.’
“But why should that matter? The dead should be treated with the same amount of respect as the living.”
Credits:
Photography:
Charles McQuillan
Additional Images:
McGinley Family, Pacemaker Press, Press Eye, Getty Images
Online Production:
Peter Hamill
Assistant Editor:
Darwin Templeton
Editor:
Pauline McKenna
Publication date: 14 January 2022
