A Wexford man died as a result of massive internal bleeding after a vein was accidently pierced during an elective procedure at the Beacon Hospital in Dublin three years ago, an inquest has heard.
Craig Tracey (56), a father of one from Parkfield, New Ross, Co Wexford, died from unexpected complications which arose during planned keyhole surgery to treat a hernia at the hospital in Sandyford on December 1st 2021.
An inquest into his death at Dublin District Coroner’s Court on Wednesday heard Mr Tracey welcomed having the procedure as it would give him relief from stomach problems he had suffered for over 20 years.
The surgeon who performed the operation explained how Mr Tracey suffered “sudden massive haemorrhaging” when he accidently cut the patient’s inferior vena cava – the body’s largest vein – in a “safe” area where it was not expected to be found.
Professor John Reynolds said he had never come across an inferior vena cava in that part of the body in over 30 years of performing surgery.
The deceased’s son, Ryan Tracey, told the inquest that he last saw his father two days before his death when he was collected from college and brought home to New Ross.
Mr Tracey said his father has suffered long-term problems from gastric reflux and that problems with his stomach and getting sick after eating had been getting progressively worse in recent years.
Asked if his father was worried about going for surgery, Mr Tracey replied that he was “raring to go” and was “delighted as he’d waited so long for it.”
He recalled his father stating: “Finally I will be better and able to live my life.”
The inquest heard that Mr Tracey had been referred to a consultant gastroenterologist by his family doctor in June 2020 because he was experiencing difficulties in swallowing, vomiting after meals and a tightness in his stomach.
Tests overseen by a consultant gastroenterologist in Waterford, Kevin Ward, contained “quite dramatic” findings about the patient’s oesophagus due to a hernia and ulcers.
The coroner, Aisling Gannon, said medical records showed that while Mr Tracey’s condition improved dramatically with medication, Dr Ward had still referred him to another specialist as “something just doesn’t feel right.”
Prof Reynolds, a consultant surgeon at the Beacon Hospital who first examined the patient in May 2021, concluded that Mr Tracey met all the criteria for surgery “to a maximum.”
He explained that the patient required surgery to treat the narrowing of his oesophagus and persistent ulcers which he regarded “at the most severe end of the spectrum” as well as to prevent more serious complications in the future.
Professor Reynolds said he had assessed Mr Tracey’s quality of life at that time as “pretty miserable.”
He said further tests showed that a measure of the patient’s acid-reflux was six times the normal level.
Prof Reynolds said he explained the procedure and discussed risks with Mr Tracey and how he expected it could be performed using keyhole surgery.
However, he said what ultimately happened was so rare that it was not a risk he had identified or mentioned to the patient.
The inquest heard how Mr Tracey suffered a large amount of blood loss and subsequent cardiac arrest about 30 minutes into the procedure when Prof Reynolds accidentally cut a vein.
Efforts by a multi-disciplinary team to open up the patient’s chest and revive him proved unsuccessful.
In reply to questions from the coroner, Prof Reynolds said what happened was “completely unexpected.”
“I don’t fully understand what happened,” he admitted.
The consultant said everything about the procedure was standardised but he had never before faced “this exact problem or anything like it.”
He believed the level of inflammation of Mr Tracey’s oesophagus had pulled the vein towards it.
Asked about pre-surgical tests on the patient he replied: “Everything that could be done was done and repeatedly so.”
Prof Reynolds said he would be happy to record the case in medical literature with the permission of the deceased’s family to raise awareness about what had happened.
The deceased’s partner, Jackie McLoughlin, told the inquest that she had not wanted him to go ahead with the procedure but could not get him to change his mind.
Ms McLoughlin said she thought the operation was unnecessary as she believed his condition could be managed through his diet.
The results of a postmortem showed that Mr Tracey died as a result of hypovolemic shock (loss of blood) due to an injury to the inferior vena cava during surgery to treat a hernia.
Returning a verdict of death by misadventure, Ms Gannon said the deceased had suffered a sudden and unforeseeable complication of the surgery and had passed away despite every effort by doctors to perform emergency support.
The coroner offered her sympathy and condolences to both Mr Tracey’s family and the surgeon.
