A young mother bled to death following a “systems failure” in her care while she was an inpatient at University Hospital Limerick, an inquest into her death has heard.
The UL Hospitals Group issued an unreserved apology to the family of Susan Doherty (47), who died at the hospital on July 4th, 2020, eight days after she presented there with a low white blood cell count, sore throat and high temperature.
Doctors requested an “urgent” scan of Ms Doherty’s abdomen and pelvis after she complained of severe pain in her chest, but this was not followed up on, the inquest on Monday heard, and she died after suffering a bleed to her spleen.
Conor Halpin, senior counsel, acting on behalf of the UL Hospitals Group, expressed his “deepest sympathies to Susan’s family” and read out a letter of unreserved apology which was signed by Noreen Spillane, chief operations officer, UL Hospitals Group.
“Patients and their families put their trust in hospitals and in healthcare professionals and on this occasion we have fallen far short of the standards of care expected,” Ms Spillane wrote.
“I wish to apologise sincerely and 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.”
Ms Spillane concluded: “Valuable lessons have been learnt by the hospital and its staff.”
Eleven recommendations were made following an internal review by the hospital group but these have yet to be implemented.
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 that fight infection. She had been routinely receiving the therapeutic GCSF, which carries a “very rare” risk of splenic rupture, it was heard.
On July 2nd, 2020, after having shown signs of improvement Ms Doherty complained of significant pain in her abdomen as well as nausea. Around 9am on July 3rd, her condition deteriorated and doctors ordered an “urgent” CT scan of her abdomen and pelvis but she was sent back to her ward after a problem accessing a cannula.
The scan was never followed up by her members of her care team.
Mary McKiernan, a senior nurse manager, who has since retired, said Ms Doherty was not monitored as per the hospital’s protocols and the patient’s ward was “short staffed”.
There was delay in weekend rostered on-call consultants being made aware of Ms Doherty’s condition, the inquest also heard.
Ms Doherty was prescribed the drug heparin after it was suspected her abdomen pain was due to a blood clot in her lung.
An “urgent” CTPA [pulmonary angiogram] was requested and prioritised over the CT scan of her abdomen and pelvis.
Ms Doherty’s condition further deteriorated and it was determined she required a bed in the high dependency unit for seriously ill patients, but none were immediately available.
Ms Doherty suffered a cardiac arrest at five minutes past midnight on July 4th, and she was transferred to the intensive care unit after doctors successfully resuscitated her.
Scans were not carried out until about 5am; the CTPA which had been prioritised over the CT scan was negative and the CT scan confirmed a major haemorrhage in Ms Doherty’s spleen.
She underwent emergency surgery to remove the ruptured spleen, but was pronounced dead around midday on July 4th.
The inquest heard that prior to being admitted to the hospital Ms Doherty had regularly been receiving GCSF for neutropenia, which carries an extremely rare risk of splenic rupture.
After she was admitted to the hospital she received the drug heparin which is used in the treatment of blood clots which may have exacerbated her internal bleeding.
Coroner John McNamara said it appeared that “a conflict” between clinicians working on the front line of the hospital and “capacity and access issues” were “at the heart” of Ms Doherty’s “tragic” death.
He said if a CT scan had been performed on her earlier, “it would have without any shadow of a doubt changed the trajectory of Susan’s treatment and eradicated doctors’ concerns about [a lung blood clot]”.
Mr McNamara said it appeared that “without a CT scan” doctors were “fighting with one hand tied behind their backs”.
He said an autopsy concluded cause of death was due to “shock intra abdominal haemorrhage, due to splenic rupture” and there was no evidence of any wrongdoing by any members of Ms Doherty’s care team.
He recorded a verdict of “medical misadventure”.
Intensive care consultant at the Limerick hospital Dr Catherine Nix told the inquest that doctors in America were using hand-held “bedside” scans to fast-track diagnosis in their patients and this technology should be used more often in UHL and other Irish hospitals.
The coroner recommended the HSE and the UL Hospitals Group consider “increased use” of these scan devices.
Ms Doherty’s husband, Roland Doherty, represented by Sara Antonioni BL instructed by Rachael Liston, Liston Flavin solicitors, Cork, said: “It’s not going to bring Susan back, but the HSE accepted there were major failings.
“They need to change their systems to ensure this doesn’t happen again, I don’t want anyone else to go through what I have been through for the last two years.”
Paying tribute to his late wife, he said: “She always had a smile on her face no matter what, and she adored the ground our beautiful daughter Charlotte Rose [now aged 5] walked on, but she only had two years with her.”