The head of the HSE has told the family of a young Limerick woman that he will arrange an independent investigation into her death.
Eve Cleary (21), from Corbally, Limerick, died at University Hospital Limerick (UHL), on July 21st, 2019, after presenting while in cardiac arrest and with a swollen leg, four hours after she had been discharged from the hospital on a wheelchair and in pain.
A verdict of medical misadventure was recorded by coroner John McNamara, following an inquest into Ms Cleary’s death held last October.
A HSE spokeswoman said: “The HSE CEO Bernard Gloster has met the Cleary family and told them he would arrange for an independent examination of their late daughter’s case.”
Mr Gloster “expressed his and the HSE’s deep sympathy with the Cleary family” during their meetings. The spokeswoman said the HSE could not discuss the probe further.
Melanie Sheehan said she and her family were “very happy” that an independent review of the circumstances of her daughter’s death was happening.
The review is to be led by an independent legal counsel, Ms Cleary said.
“We were told it would start in the next couple of weeks, they are anxious to get it started because Eve will be dead four years in July, and they said they are very conscious of the time that we have already lost.”
“We are fully involved, we are delighted, because this is what we wanted all along.”
“I hope Eve’s whole truth and story will come out. Getting justice for Eve is all this has ever been about.”
Foul smells
Last October, Limerick Coroner’s Court heard Eve Cleary presented at UHL on July 19th, 2019, with a swollen right leg following a fall.
For 17 hours Ms Cleary languished on a trolley in a foul-smelling section of a corridor in the hospital’s emergency eepartment (ED), which at the time was swamped by a “record” number of trolleys.
Ms Cleary’s parents told the inquest they discovered their daughter on a trolley close to a sink that another patient had used as a toilet.
Melanie Sheehan said: “The smell of urine caught in my breath and made me cough”.
Eve Cleary had presented at the hospital with a number of risk factors for thrombosis and blood clots, it was heard.
When she was eventually admitted to a ward on July 20th, her patient files appeared to be missing and the ward nurses were not fully aware of why she was there.
The hospital was operating on a skeletal staff, and no one was available to operate the hospital’s ultrasound equipment, which along with a blood test, are the two main methods of diagnosing blood clots, it was heard.
Ms Cleary was not assessed for risk of blood clots, despite having a family history of blood clots, and presenting at the hospital with several risk factors.
It was accepted she was never physically seen by a consultant doctor, although a report of a CT scan performed on her leg was read by a consultant orthopedic doctor who did not find any abnormalities in the scan.
Ms Cleary was discharged from UHL with a suspected soft tissue fracture of her leg.
Melanie Sheehan wept giving evidence at the inquest that she saw her daughter’s leg swell to “three and half times” its normal size in the hospital.
She said her daughter’s leg had turned dark red “like the colour of a Christmas ham”.
Evidence was also heard that Ms Cleary sent a text message to a work colleague indicating she believed those involved in her care were considering she may have had a blood clot. However, some of those involved in Ms Cleary’s care told the inquest that at no stage was it ever considered she was suffering from a blood clot.
Cardiac arrest
Despite being unable to walk because she was in severe pain, Ms Cleary was discharged from the hospital in a wheelchair.
Four hours later she went into cardiac arrest at her home.
In his evidence to the inquest Barry Cleary wept while describing how he desperately tried to save his daughter by performing chest compressions and CPR on her, after she collapsed at the family home.
Ms Cleary was rushed by ambulance back to UHL where she was pronounced dead at 1.50am on July 21st, 2019.
A postmortem conducted by pathologist Dr Teresa Laszlo recorded Ms Cleary’s death was due to cardiac arrest brought on by extensive bilateral thrombo-embolisation/or clots that blocked up Ms Cleary’s lungs.
Counsel for the Cleary family Doireann O’Mahony BL told the inquest that it was “insulting” to her family that no formal apology had been offered to them surrounding her death.
Coroner John McNamara said there had been “missed opportunities” in Ms Cleary’s care, but he stressed this was not to fault anyone involved in her care.
Mr McNamara said he accepted Ms Cleary’s parents’ “harrowing evidence” about what they had witnessed in the overcrowded hospital.
Ms Cleary’s parents said afterwards that their daughter’s death could have been prevented and that she had been “failed” by those tasked with her care.
Barry Cleary said the overcrowded ED was similar to a busy “cattle mart” due to the high numbers patients languishing on trolleys.
