The family of a 34-year-old “doting” father of one who died after he spent nine hours on a chair at Cork University Hospital (CUH) before he was seen by a doctor and had a CT scan delayed because a machine was broken have warned that lessons must be learned to prevent further tragedies.
Cork chemical engineer Pat Murphy died of an aortic dissection on September 3rd, 2021 at CUH having been misdiagnosed with a possible kidney stone and renal colic.
He went to the hospital by taxi with chest pain late in the evening of September 1st, 2021 and a CT scan was ordered. His arrival at hospital was delayed because his ambulance failed to arrive.
Triaged as a Category 3 patient, the PHD graduate of Lancaster University should have been seen by a doctor within an hour.
An inquest at Cork Coroner’s Court heard that he spent nine hours in complete agony on a chair in the A&E department.
At times, he was in so much pain that he tried to lie on the floor to ease it.
Broken scanner
His CT scan was postponed by eleven hours because one of two CT scanners onsite was broken.
The inquest heard that potentially life saving hours were lost because of the failure to reach the appropriate diagnosis. Pat underwent emergency surgery but unfortunately efforts to save his life failed.
He is survived by his wife Keerti Krishnan Murphy and their young son who was just 17 months old when he lost his father. He is also survived by his parents, Willie and Noreen, and his siblings Sinead, Yvonne, Suzanne and Tracy.
Ms Krishnan Murphy said that she has learned from the Aortic Dissection Charitable Trust that with “proper intervention and well documented symptoms many lives could be saved.”
Meanwhile, Assistant State Pathologist Dr Margaret Bolster carried out a postmortem on Mr Murphy. She told the inquest Pat died from a dissected aortic aneurysm with the sack around his heart filling with blood.
Dr Bolster said that Pat suffered severe brain damage due to lack of oxygen to the brain. The damage to the aorta was quite extensive.
Dr Bolster said that there is a “very high mortality rate” for aortic dissection.
"It is a rare and life-threatening condition. Prompt and proper diagnosis and treatment is vital."
She said that aortic dissection is a life-threatening condition with a mortality rate which increases by one to two percent an hour which requires prompt and proper diagnosis and treatment.
Dr Bolster added that aortic dissection is rare in a person under the age of 40.
Timeframe
Dr Frank Leader, Head of Education and Training at CUH Emergency Department, was asked why it took nine hours for Pat to be seen by a doctor, given that he was triaged as a Category 3 patient and ideally would have been seen within an hour.
Dr Leader said that it was “extraordinarily difficult” to meet that timeframe.
“Category 1 is seen instantly. Our Category 2 patients certainly are very assiduous in as close to the ten-minute time frame as possible.
Category Three patients will unfortunately have to wait much longer than (the guideline) one hour. We just do not have the resources to see (these) patients within an hour. Internationally, it is an issue. We currently have the busiest emergency department in the country.
Dr Leader stated that the emergency department at CUH currently handles in the region of 90,000 cases a year.
"There are days when we see more than 300 patients. It is extremely challenging and that would have been the case in 2021."
Dr Leader indicated that three years ago CUH had three doctors on duty at night in the A&E Department, two registrars and one junior doctor with a consultant on call. At times, staffing pressures were such that there might be one registrar and two junior doctors/senior house officers. (SHO’s)
However, Dr Leader said the numbers have now increased to five doctors, registrars and three junior doctors with a larger number of consultants also available.
"The resources have increased. Our senior cohort has doubled since 2021. We also have more junior doctors and SHOs. There has been a significant increase in staff."
"(But) it (the A&E) was and remains under pressure."
Improvements in hospitals
Dr Leader said that the Murphy case was discussed at length at their monthly clinical risk meeting. He said that lessons were digested and disseminated to the department at large.
Other improvements implemented at CUH include special orientation training for doctors on aortic dissection, the hiring of more senior doctors and increased case discussions, an expanded email reference platform and the allocating of consultants to specific areas.
Dr Leader said that it was “very clear” that a wrong diagnosis was reached and that the “best care” would have been to organise an urgent CT scan of the aorta.
Doireann O’Mahony, Junior Counsel, for the family said that Pat was being viewed in the hospital as a person who was possibly suffering from kidney stones and renal colic.
“Every step taken was as a result of misdiagnosis. Everyone was singing from the same hymn sheet and it was the wrong hymn sheet.
Dr John O’Mahony, SC, made legal submissions to the jury on behalf of the family.
He said that their verdict was “sacrosanct” and said that it was vital that they get it right. Dr O’Mahony said that the case should have been “urgent from the get go.”
“This was a mistaken path and outcome. As a consequence of which, in the early hours of the third, the management said we are on the wrong path here. That road was, of course, an aortic dissection which we all heard a lot of.
Unfortunately, there was a lot of time lost. It is a tailor-made case of medical misadventure. There is no other verdict which comes near medical misadventure. “
Doireann O’Mahony spoke to the jury about possible recommendations which could be made in the case.
“The sad reality is that nothing is going to bring Pat back. Their glimmer of hope is that recommendations will be made which will shield other families from the devastating pain they have gone through.
Her first recommendation was that the hospital management audit radiological infrastructure to identify areas for improvement and investment.
Her second recommendation was that CUH introduce a dedicated aortic dissection policy. The third recommendation she suggested involved learning.
“If anything is going to come from Pat’s death it is going to be learning. We would suggest you come up with a proposal that learning happen at CUH re this time critical medical emergency which caught in time is salvageable.
She called for more training on Aortic dissection at CUH so that Pat’s death not be in vain.
Barrister for CUH Caoimhe Daly, BL, said that a verdict of medical misadventure wasn’t in keeping with the facts of the case.
“What took hold on Mr Murphy when he as watching that match is ultimately what killed him.”
She said that the most appropriate verdict was a narrative verdict.
A narrative verdict was recorded in the case via a 7-1 majority verdict.. The jury recommended that electronic records be introduced urgently at CUH. This recommendation had been suggested by the Coronet.
Coroner Philip Comyn extended his heartfelt condolences to the family of the deceased following their “out of the blue” tragedy. He said that certain learnings would be made following their tragic notices.
Condolences were also offered by Sgt Fergus Twomey, Caoimhe Daly and Dr John O’Mahony.
Management at CUH have apologised to the Murphy family for failings in the care of their loved one.
