Bereft family angered at unanswered questions over 'preventable' death

After seven years, the Actons continue to seek an inquiry, but without success

Peter Acton, a 61-year-old painter-decorator from Clondalkin in Dublin, was admitted to Tallaght hospital on September 27th, 2005, and diagnosed with pneumonia, but discharged the following day.

He was readmitted on October 1st with pneumonia and “renal impairment secondary to dehydration and arterial flutter secondary to sepsis or pneumonia”.

“He hadn’t eaten for days, he was dehydrated and lethargic,” his daughter Lisa Acton-Burke recalls.

‘Shoot me’

Mr Acton was treated with intravenous antibiotics and fluids, but the cannula supplying the fluid came out of the vein at about 1pm on Sunday, October 2nd, and had to be removed. “At that stage, both my mother and I could see that my father’s condition had not improved and he was constantly asking for a drink. We could not give him a drink as a ‘nil by mouth’ sign hung above his bed,” says Ms Acton-Burke.

“Dad was saying, ‘Get me a gun and shoot me’, which wasn’t like him at all,” says his son Darren.

The doctor tasked with reinserting the cannula did not arrive until about 6pm but was unable to get a vein, she says. With Mr Acton’s condition deteriorating, he was transferred to the intensive care unit later that evening. He died at 9.40am the following day due to sepsis and organ failure.

The family engaged Dr David Sinclair, a UK-based consultant respiratory doctor to review the medical records. His report is highly critical of the hospital’s management of the deceased.

‘Deteriorating situation’

“Mr Acton’s death was entirely the result of a failure to appreciate the severity of his condition at the time of presentation together with a failure to act accordingly upon what are well recognised to be adverse prognostic indicators together with a subsequent failure to respond to what was clearly a deteriorating situation, in terms of metabolic acidosis, low blood pressure and loss of urine output.”

Dr Sinclair concluded that Mr Acton’s death was “entirely due to medical negligence and was in my opinion preventable”.

The first death certificate wrongly stated the cause of death to be oesophageal cancer. Ms Acton-Burke says this was “offensive”. “My father had undergone treatment for his cancer and had been discharged from Tallaght two years earlier with no subsequent problems. In light of events, we felt this was totally wrong.”

The family approached the advocacy board, which arranged a meeting with the consultant who treated Mr Acton. “We were told that my father had died of a ‘catastrophic cascade of errors’ and that the hospital had ‘failed’ my father and my family,” she says.

When they later asked for the minutes of this meeting, they were told they had gone missing. The family asked the board for an investigation, but none has taken place.

“Our questions have never been answered. Nobody had ever been brought to account before any forum in relation to the death of my father. We feel we are being denied our right to have answers to our questions.”

The Actons also brought their concerns to the Health Information and Quality Authority (Hiqa), which said it had no remit to investigate an individual death in a hospital. Family members provided testimony to Hiqa before it published a highly critical report about the hospital last year.

The Medical Council also took the view that it could not investigate a hospital. The Actons have not been told the names of the staff members who treated their father and so are not in a position to ask the council to hold a fitness-to-practise hearing into issues of medical negligence.

Last February, the family reported the death to gardaí, who are awaiting the outcome of the inquest before deciding what action, if any, to take.

Seven years on, the anger of the family is palpable. “I would have thought fluids management was basic medicine. They let him dehydrate to death,” says Ms Acton-Burke.