A verdict of medical misadventure has been returned into the death of a woman from a life-threatening condition which was not picked up by medical staff at a Dublin hospital.
Deborah Duffy (50), a married mother of two from Delmere, Enfield, Co Meath, died at Connolly Hospital Blanchardstown on February 4th, 2018 from a severe loss of blood due to an aortic dissection – a condition where there is a tear in the body’s main artery.
The former childminder died less than 24 hours after being brought to the hospital by ambulance after complaining of severe chest pains.
Her husband, David Duffy, had told the coroner Cróna Gallagher that his wife had "never been sick a day in her life."
Evidence heard at Dublin District Coroner’s Court over a two-day inquest into Ms Duffy’s death which concluded on Tuesday revealed that the patient was only seen by junior doctors during her stay in the hospital and her condition was never reviewed by a registrar or consultant.
Test results
It also heard that test results showing “critical” levels of a protein in the blood which signifies damage to the heart, which were notified to a nurse, were not elevated further.
The coroner was also informed that no CT scan, which could have helped medical staff to diagnose aortic dissection, had been carried out on Ms Duffy.
The inquest heard that medical staff had focused on a blood clot on the lung as being the likely cause of the pain being felt by the patient.
In a closing submission, counsel for Ms Duffy’s family, Sara Antoniotti SC, said hospital staff had not properly investigated a murmur in Ms Duffy’s heart and her severe chest pains which were classic symptoms of aortic dissection.
Ms Antoniotti said it was also unclear when a CT scan which was recommended by a junior doctor would have been carried out as Ms Duffy had been admitted on a Saturday.
She said there were also assessments conducted on the patient which showed that a blood clot was an unlikely cause of her condition.
In addition, Ms Antoniotti said the patient had been prescribed a blood thinner which, given the wrong diagnosis, would have exacerbated her situation.
She also noted that “nothing appears to have happened” after a nurse, Liz Kelly, received the critical test results.
Ms Antoniotti observed that Ms Kelly, who was unavailable to give evidence to the inquest, had made no reference to receiving the results in a deposition provided to the coroner.
“Ms Duffy was not examined by any doctor more senior than a senior house officer with six months' experience as a SHO,” she remarked.
She added: “There was no contact with a registrar in a 24/7 major teaching hospital.”
'Unmonitored and unattended'
Calling for a verdict of medical misadventure, Ms Antoniotti said: “She was unmonitored and unattended and effectively left alone in a cubicle. It almost seems beyond comprehension.”
Counsel for the hospital, Rory White BL, reminded the coroner that she had heard evidence that aortic dissection is a very rare condition which is difficult to diagnose.
Mr White pointed out that it was fatal in around 25 per cent of cases.
He also noted that there was an overlap in the symptoms of aortic dissection and a blood clot and that the doctor who had treated Ms Duffy had not expected a diagnosis of the rarer condition.
Mr White said the failure to inform the doctor of the test results had deprived her of important medical information which could have prompted her to reassess the care of the patient.
However, he said Ms Duffy’s care had not been changed as she had appeared in a stable condition in what was “an unfortunate and tragic mishap.”
Mr White argued a narrative verdict was appropriate to reflect the breadth and complexity of the case.
Verdict
In her ruling, coroner Cróna Gallagher said Ms Duffy was last seen alive at 2.30am on February 4th, 2018, but no observations had been performed.
The patient was found in an unresponsive state at 6.20am and was pronounced dead 20 minutes later.
Dr Gallagher noted that Ms Duffy’s body had shown signs of rigor mortis.
The coroner said her finding of medical misadventure in relation to Ms Duffy’s death was “a neutral verdict” and was not seeking to find fault with any party.
“It was the unintended outcome of the course of actions and the way the hospital system operated,” Dr Gallagher remarked.
The coroner said she endorsed changes that had already been made at Connolly Hospital Blanchardstown since Ms Duffy’s death.
They included the ongoing education of medical staff in relation to raising awareness of aortic dissection and encouraging junior staff to confer with more senior colleagues about the care of patients.
Dr Gallagher said she was aware that there were ongoing challenges in relation to staffing levels and resources within hospitals but she did not believe she should make any general recommendations on the issue.
Out of hours care
However, the coroner said she had concerns about the ability of medical staff to access diagnostic tools such as CT scans and echocardiograms during out of hours and at weekends at Connolly Hospital Blanchardstown and would communicate them to the HSE.
Offering her condolences to the deceased’s family, Dr Gallagher said they had suffered “an unspeakable shock.”
The family’s solicitor, Rachael Liston, said they were happy with the outcome of the inquest.
Speaking outside the coroner’s court, Mr Duffy said he also welcomed the recommendation made by the coroner.
“I generally hope that things will improve with the HSE as I don’t want this to happen to someone else,” he added.
