A patient at Wexford General Hospital suffered fatal internal bleeding after medical staff missed several opportunities to intervene to address her deteriorating condition, an inquest has heard.
A verdict of medical misadventure was returned into the death of Marie Lynch after Wexford county coroner, Seán Nixon, said there had been delays in treatment being provided to the patient.
Ms Lynch (75) of St Aidan’s Villas, Enniscorthy, Co. Wexford died at Wexford General Hospital on March 24th, 2021.
An inquest into her death at Wexford Coroner’s Court in Gorey on Friday also heard claims that the patient had suffered internal blood loss as a result of anti-blood clotting medicine that she had been given longer than necessary.
Dr Nixon heard Ms Lynch had been a very active grandmother who was “more like a sister” to her children and grandchildren before her admission to hospital.
The solicitor for Ms Lynch’s family, Ambrose Cuddy, said she was admitted for treatment to Wexford General Hospital on March 11, 2021, with a painful leg following a fall and had been diagnosed with cellulitis.
The inquest heard that she was given an anticoagulant to prevent blood clots on March 18, 2021, which was prescribed in increased doses from the following day.
CT Scan
Mr Cuddy said a CT scan to check for clots on the lung was ordered on Friday, March 19 2021 but it was not carried out until three days later.
He observed that it seemed that it was bad to be in hospital over a weekend as “nothing happens.”
Mr Cuddy said the CT scan taken on March 22, 2021, showed there was no clot on the patient’s lung but her treatment with the anticoagulant was not stopped for a further 24 hours even though her condition was deteriorating.
By the following day, the solicitor said Ms Lynch was vomiting blood and also passing blood in her stool as well as suffering nosebleeds.
Mr Cuddy said extensive bleeding in the patient could have been addressed by a blood transfusion.
The inquest heard she died in the early hours of March 24, 2021, after suffering a cardiac arrest.
“Ms Lynch’s family were tormented and frightened and have a total loss of confidence in Wexford General Hospital,” said Mr Cuddy.
Postmortem
A postmortem showed Ms Lynch had died as a result of hypovolemic shock due to blood loss at multiple sites within her body.
The inquest heard that the patient suffered internal bleeding of up to 1.3 litres of blood, while an additional unmeasured quantity of blood was also found in her pelvic area.
Pathologist, Mutaz Nur said he could not say the use of the anti-coagulant was definitely responsible for the blood loss but accepted it was probably a contributory factor.
Cross-examined by Mr Cuddy, Dr Nur greed that Ms Lynch had suffered significant internal bleeding.
The pathologist said it was not possible to say when the blood loss had started but he accepted there had been a significant loss of blood over a short period of time.
A consultant physician at Wexford General Hospital, Professor Colm Quigley, said it was standard practice to give an anticoagulant to a patient who was at risk of deep vein thrombosis like Ms Lynch.
“It was entirely appropriate,” the consultant remarked.
However, Prof Quigley admitted he was unhappy that a CT scan he ordered for Ms Lynch on March 19, 2021, was not carried out for a further three days.
Prof Quigley accepted there could have been earlier intervention from March 23, 2021, to address the patient’s deteriorating condition.
He believed there was “a window” of about three hours up to 9 pm that day when Ms Lynch’s condition could have been stabilised with a blood transfusion.
Since the patient’s death, Prof Quigley said improvements had been made in the training of staff at Wexford General Hospital about recognising patients with a deteriorating condition.
However, Prof Quigley said the failure to recognise a deterioration in patients and to provide a rapid response in hospitals was “a national issue.”
Offering his condolences to Ms Lynch’s relatives, he said staff at Wexford General Hospital would be happy to meet them if they still had further questions about the case.
Missed opportunities
Returning a verdict of medical misadventure, Dr Nixon said there was evidence “of a lot of missed opportunities” and a failure to escalate treatment for her deteriorating condition.
The coroner said there had also been a significant delay in carrying out the CT scan on Ms Lynch and in addressing her internal bleeding, particularly in the final 24 hours of her life.
Dr Nixon said there had also been an issue with maintaining correct and adequate medical notes about the patient’s care.
He welcomed “a lot of good recommendations” that had come from a review by Wexford General Hospital of its care of Ms Lynch.
Speaking after the inquest, Ms Lynch’s daughter, Wendy Walsh, said her mother had never been a hospital patient before apart from the birth of her five children.
Ms Walsh said she and her siblings had been unable to visit their mother in hospital due to Covid-19 restrictions.
She said she last spoke to her mother on March 23rd, 2021, when she had complained about vomiting and passing blood.
“Little did I know that the care she was receiving was below standard and her life hung in the balance,” said Ms Walsh.
She added: “I trusted in a system which would eventually take the most precious person from me.”
Ms Walsh said she felt “sick to the pit of my stomach” after reading reports from the hospital about her mother which admitted mistakes but offered no apology.
Welcoming the verdict of medical misadventure, Ms Walsh said her family had to push for a postmortem to be carried out to establish the cause of her death.
“I will forever regret not asking more questions. Not pushing harder to get into see her knowing that if I had, I would not have left until she was taken care of,” she remarked.
Seán McCárthaigh
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