A 47-YEAR-OLD father of three died in a hospital toilet from cardiac failure after hospital staff failed to properly monitor a piece of electronic equipment designed to alert them to any cardiac event suffered by patients, an inquest heard yesterday.
Richard Cassidy, from Ballytrasna, Lissarda, Co Cork, was found collapsed in a toilet in Cork University Hospital at 11am on February 25th last and when medical staff went to check on a telemetry device monitoring his heart, they found it had been switched off.
The inquest into Mr Cassidy’s death heard he had been admitted to the hospital on February 19th after two weeks of intermittent chest pains. He had a stent inserted in the hospital’s new coronary care unit on February 21st.
The procedure went well and two days later he was moved to a stepdown unit. He was able to walk around while being monitored remotely via wireless telemetry at the nurses’ station in the coronary care unit where any cardiac events would register on a monitor.
The device, which was essentially a portable ECG unit, first emits a yellow alert for two minutes involving both a visual and an audio warning before it upgrades to a more serious red alert to indicate that a patient is experiencing a serious cardiac emergency.
The coronary care unit was down one staff member on February 25th when a nurse reported sick, leaving clinical nurse manager Anne O’Dwyer and staff nurses Nija Abraham and Ancy Antony to care for 10 patients and monitor the telemetry that day.
Ms O’Dwyer said she checked the telemetry before she left on her break at 9.30am and it was all in order. When she returned at 10.10am, she saw that the telemetry screen had gone black and had shut down so she switched it back on.
Ms Abraham said Ms O’Dwyer left to go on her break between 9.40am and 9.45am and she had not been monitoring the telemetry as she was looking after three patients and she had never worked on the telemetry before. She had not turned it off.
Ms Antony said she had not been monitoring the telemetry as she was helping a patient to shower. She did not turn it off, she said.
Neither the staff nurses nor Ms O’Dwyer said they heard any alarms ring out in the coronary care unit.
Consultant cardiologist Peter Kearney said it appeared from trace records on the telemetry that Mr Cassidy had suffered cardiac failure at about 9.30am and at least 30 minutes elapsed before he was found, making resuscitation an impossibility.
He said protocols had changed at the hospital since Mr Cassidy’s death to ensure the telemetry is now constantly monitored.
“The telemetry needs monitoring – that is the purpose of it – it is a safety net,” he told the inquest.
Bernard Murphy, a biomedical engineer at the hospital, said he tested the telemetry later and found it was working properly. Tests by both the supplier and manufacturer confirmed this.
He examined the machine’s records and found it had first issued a yellow alert regarding Mr Cassidy’s heart condition at 9.30.06am and two minutes later issued a more serious red alert which lasted for some 40 seconds before it was switched off by somebody.
The inquest did not hear who turned it off.
The jury returned a narrative verdict that Mr Cassidy died from acute congestive cardiac failure.