A mother bled to death following a “systems failure” in her care, an inquest heard yesterday.
The UL Hospitals Group apologised to the family of Susan Doherty, 47, who died in University Hospital Limerick, July 4, 2020, eight days after she presented there with a low white blood cell count, sore throat and high temperature.
Doctors requested an “urgent” scan after she complained of severe pain in her chest, but this was not followed up on, and she died after suffering a massive bleed to her spleen.
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Ms Doherty presented at UHL with a medical history of rheumatoid arthritis and autoimmune neutropenia - a blood disorder where the immune system attacks white blood cells.
By the time she received the “urgent” CT scan nearly 24 hours later she had suffered a cardiac arrest.
Senior Counsel for ULH Group Conor Halpin read out a letter of unreversed apology which was signed by Noreen Spillane, chief operations officer.
She wrote: “I apologise unreservedly for the sorrow and distress caused to you and your family over Susan’s untimely death and for the personal trauma experienced by you and your family.”
Eleven recommendations made following an internal review have yet to be implemented. Retired senior nurse manager Mary McKiernan said Ms Doherty was not monitored as per protocol and the patient’s ward was “short staffed”.
It was heard there was delay in weekend rostered on-call consultants being made aware of her condition.
Ms Doherty was prescribed heparin after it was suspected her abdomen pain was due to a blood clot in her lung. An “urgent” CTPA (pulmonary angiogram) was prioritised over the CT scan of her abdomen and pelvis.
Ms Doherty’s condition further deteriorated and she required a bed in the high dependency unit but none were immediately available.
She suffered a cardiac arrest just after midnight on July 4, she was transferred to ICU after doctors resuscitated her.
Scans were not carried out until around 5am; the CTPA which had been prioritised over the CT scan was negative and the CT scan confirmed a major haemorrhage in her spleen.
She underwent emergency surgery to remove the ruptured spleen, but was pronounced dead around midday on July 4.
Coroner John McNamara recorded a verdict of “medical misadventure” but found there was no evidence of any wrongdoing by anyone involved in Ms Doherty’s care.
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