A young man who died in the emergency department of Tallaght University Hospital three years ago had been waiting 11 hours to be seen by a doctor when he should have been categorised as a patient in need of “urgent” care who should have been examined within 10 minutes.
An inquest at Dublin District Coroner’s Court heard evidence by several nursing staff at TUH that the emergency department was experiencing significant overcrowding and understaffing at the time.
The coroner, Clare Keane, was informed that the patient should have been given a higher priority for being seen by a doctor but triage staff had been given two different versions of a system used for assessing patients which had resulted in him being deemed in less urgent need of care.
Gary Crowley (35) a security guard from Killinarden Estate, Tallaght, died at TUH on September 21st, 2021 after suffering a cardiac arrest.
The inquest heard that Mr Crowley had called his sister from the hospital a few hours earlier complaining of severe pains all over his body but felt he was being ignored by nurses.
Claire Crowley said her brother, who lived at home with their parents, rang her to say he felt unwell on the morning of September 20th, 2021 but did not want to tell their mother, Anne, who was travelling to Lourdes that day.
The inquest heard Mr Crowley had been taking anti-blood clotting medication for several years to treat deep vein thrombosis.
He was also diagnosed with a borderline personality disorder and was a heavy drinker.
Evidence
Evidence was heard that Mr Crowley had been vomiting for four days and had drunk a bottle of rum every day for the three days prior to his admission to TUH.
Ms Crowley planned to call over to bring him to hospital but discovered that their father had brought him straight away because of his condition.
As she was unable to attend the hospital because of Covid-19 restrictions, Ms Crowley said her brother called her around 7pm where he described feeling ignored by nurses.
At the time Ms Crowley said her brother, who had been sitting in a plastic chair, wanted to lie down as he had “extremely bad pains everywhere” and an irregular heartbeat.
She received a final text from him at 10.30pm when he wrote: “Don’t worry. I’ll be alright.”
Ms Crowley complained that her family had not got clear communications or adequate information from the hospital about his condition.
She described how her brother’s death had a devastating effect on all her family, particularly her father, Gus, who had been in and out of hospital since his son’s death.
“If we can get some sort of justice from this for Gary, it would prevent something like this from happening to another person,” she added.
Ms Crowley revealed her family had been contacted by an off-duty nurse, Danielle Connolly, who was in the emergency department who had noticed Mr Crowley in distress and coughing up “coffee-brown blood".
She claimed Ms Connolly told her that she had twice “raised a flag” about Mr Crowley’s condition with staff at a nursing station and pointing out that his care should be prioritised over her own relative, but she had been “sent away".
A nurse, Fiona Regan, said TUH’s emergency department was extremely short-staffed at the time with only two nurses available to triage patients – half the usual number.
Ms Regan said 111 patients had presented to the emergency department during her shift that day.
The inquest heard Mr Crowley was registered by TUH at 12.13pm but was not triaged for almost two hours when all arrivals should have been seen within 15 minutes.
Ms Regan admitted to the coroner that she had categorised Mr Crowley as a Category 3 patient based on an assessment tool which meant he should be examined by a doctor within one hour.
However, she acknowledged that under a different version of the same tool available in the hospital the patient should have been classified as Category 2 which was for more urgent cases with a recommended medical examination within 10 minutes.
Elevated early warning score
Ms Regan said an elevated early warning score recorded for Mr Crowley was not highlighted to other medical staff at the time but would be under a new system now operated by TUH.
She also revealed that she had completed an incident form at the end of her shift that night to raise concern about overcrowding and lack of staff in the emergency department.
Another triage nurse, Carol Greene, described finding Mr Crowley lying on the floor of a waiting area at 9.25pm due to his pains.
Ms Greene said she helped him into a wheelchair and brought the patient to another waiting area where she passed on her concerns about his condition to another nurse.
Dr Gavin Sedgwick, who was a senior house officer at the time at TUH, said Mr Crowley was in distress and he had prescribed IV fluids for the patient who he examined at 11.05pm.
Staff nurse, Danilo Garin, said he had been unable to give the IV fluids to the patient until around 1am.
Mr Garin explained he was delayed in finding another nurse to sign off on administering the medication due to staff shortages and a busy workload.
The nurse said Mr Crowley was lying on a trolley in distress when he arrived with the IV fluids and the patient suddenly became unresponsive.
He immediately sought help but efforts to resuscitate Mr Crowley were unsuccessful and he was pronounced dead at 2.45am.
A consultant in emergency medicine, Aileen McCabe, said the treatment given to the patient was correct but added: “Unfortunately it was delayed.”
Dr McCabe said tests showed the patient had suffered an acute kidney injury from dehydration.
Postmortem results confirmed Mr Crowley died from metabolic ketoacidosis and upper gastrointestinal bleeding.
Dr McCabe told the coroner that changes had been made at TUH since Mr Crowley’s death including blood tests being ordered and completed within an hour in some cases before a patient is triaged.
The consultant said any patient with abnormal test results would be prioritised for care, while a colour-coded priority system is used to alert staff to the most urgent cases.
She added: “We have significantly enhanced our safety systems particularly for patients waiting to be seen.”
Dr McCabe told the inquest that 56 patients were waiting to be examined by a doctor at 9.30pm on the day Mr Crowley was there with a further 13 patients waiting to be triaged.
Although the department now had additional staffing levels, the consultant said the number of doctors was still “inadequate” for the volume of patients coming to the hospital as was the clinical space for examining them.
Dr Mr Cabe said the number of people attending the emergency department had increased despite the ending of the Covid-19 pandemic with up to 6,000 now presenting on average per month.
She outlined how patients due to be admitted to the hospital were now moved to wards that were “already at full capacity” when the emergency department reached its own capacity of 71 patients under a new escalation policy.
Returning a verdict of death by misadventure, Dr Keane said she was deeply sorry for the pain, suffering and loss, felt by Mr Crowley’s family.
The coroner also acknowledged how staff at TUH were working in “extremely challenging conditions” and remarked that the extreme pressure they faced was “very clearly established and heard.”
