A 33-year-old mother died after Cork University Hospital (CUH) failed to detect that she had swallowed her denture when she first presented to the emergency department, the High Court has heard.
The case of Beata Kunicka from Kanturk, Co Cork, who was “wrongly discharged”, has now led to changes in hospitals across the country.
The High Court on Friday heard CUH has apologised to Ms Kunicka's family “for the deficiencies in the care” provided to her.
Ms Kunicka returned to CUH 17 days after first being discharged from the emergency department, when she collapsed at home and was vomiting blood. She died over 20 hours later, on October 12th, 2021, and hours after the embedded denture was removed from her oesophagus.
The family’s counsel, Gabriel Gavigan SC, instructed by Tracey Solicitors, told the court that liability was never contested by the HSE and the proceedings brought by Ms Kunicka’s partner, Kamil Jarzembski, were settled for €450,000 after mediation.
The young mother first went to hospital A&E on September 25th, 2021, complaining of chest pain and reporting that she believed she had recently swallowed her dentures, which were two front teeth, supportive pallet and wiring.
A plain film X-ray of her chest was arranged, and she was given a small test meal to assess her ability to swallow. She was also given painkillers to treat her chest pain.
However, no foreign body showed up on the X-ray and Ms Kunicka, who was able to eat and drink, was discharged.
Mr Gavigan told the court that the hospital chief executive, David Donegan, wrote in a letter to Ms Kunicka’s partner Kamil Jarzembski last year that an external review into the care of Ms Kunicka made clear “that we failed to identify that her dental plate had indeed been swallowed and as such wrongly discharged her when she first presented to ED”.
Medical staff, the letter said, were not aware at the time that some denture plates would not show up on X-ray and “mistakenly decided that because she was able to eat and drink it was safe to discharge her.”
It added that CUH has taken action to highlight these risks nationally to regulators and the HSE and amended its own local clinical training.
Mr Gavigan said Ms Kunicka returned to CUH on October 12th after 1am.
She was not assessed in the ED until 7am and she was vomiting blood. It was ordered she be given blood and a CT scan was arranged.
She collapsed again and later underwent surgery where the embedded denture was removed. However, she suffered severe bleeding and had to be again stabilised.
It was claimed that there was a delay in further treatment due to there being disagreement as regards the diagnosis and in the hours that followed there was prolonged discussion of the case.
Ms Kunicka became critically unstable and was haemorrhaging from her ear, nose and mouth. She continued to deteriorate and went into shock and died from cardiac arrest after resuscitation efforts failed.
Mr Gavigan told the court the letter from the hospital chief executive stated that the review also outlined the care of Ms Kunicka in the hospital when she returned there on October 12th.
It said it was a complex and challenging presentation but “it was clear that a number of elements for care were not delivered promptly enough. Furthermore, clinical differences of opinion about the source for continued bleeding, the right course of corrective action and the availability of the necessary expertise to deliver it, all delayed her receiving the care she needed.”
Ms Justice Leonie Reynolds offered her condolences to Mr Jarzemnski and their young daughter Julia over “the very tragic series of events” and she hoped they took some comfort from the review and that the recommendations have been shared nationally to ensure such an incident does not happen in an Irish hospital again.
