Different verdict and cause of death recorded at second inquest into Limerick man’s death

Coroner says changed findings regarding Michael Daly Snr do ‘not carry any connotations’ of blame or liability

A different verdict and cause of death have been recorded following a second inquest into the death of a father of six from Limerick City.

Limerick Coroner John McNamara recorded a verdict of medical misadventure in respect of Michael Daly Snr (64), formerly of Lee Estate. A verdict of natural causes was recorded after the original inquest in 2012.

The second inquest heard that Michael Daly Jnr discovered information after trawling through his late father’s medical notes, which were not available at the time of the postmortem in April 2010.

Mr McNamara also formally recorded that the 2012 cause of death finding should be modified from cardiac (heart) failure to cardiac failure and cardiac disease on a background of recent bowel cancer, surgeries, infection, sepsis, and peritonitis.


His decision was based upon a review of the case by former State pathologist Prof Marie Cassidy, who was commissioned by the coroner as an independent expert witness.

Mr Daly developed rectal cancer in 2007 and Dr Raphael Keane, then a consultant colorectal surgeon at University Hospital Limerick, successfully removed a large tumour from Mr Daly’s bowel and performed a procedure to divert his bowel movements away from the surgical wound.

Mr Daly “subsequently developed an anastomotic leak which is a risk associated with this type of procedure”, the coroner said. Despite there being an 80 per cent chance of a recurrence of Mr Daly’s cancer, it “never developed”.

‘Progressively unwell’

However, he said that following a stoma reversal, performed by Dr Keane, Mr Daly “became unfortunately progressively unwell”.

Through 2008 to 2010, Mr Daly suffered symptoms “consistent with chronic inflammation” and “underwent a lot of tests and investigations at the hospital” but the cause of his ongoing illness was never established, the coroner said.

Mr McNamara highlighted two CT scans taken of Mr Daly’s abdomen and pelvis - one on September 9th, 2008 and the second on February 16th, 2009, which he said were “significant” to the case.

Dr James Young Graham, a consultant radiologist, acting as an independent witness on behalf of the coroner, had given evidence that he found “significant and unexpected findings” on the 2008 scan.

Mr McNamara said Dr Graham gave evidence that “he would have brought this to the attention of the clinician” and the case would have been reviewed further. He said Fintan Wallis, the consultant radiologist who performed the 2008 and 2009 scans, told the inquest that “the information he received before he carried out the scans was patchy”.

The coroner said that while Mr Wallis had not agreed with everything Dr Graham said, his direct evidence was “that he was unaware Mr Daly had been sick and unwell” and that “he accepted that he misinterpreted or misread the scan having read and heard Dr Graham’s evidence”.

Mr McNamara said Dr Keane “in his evidence last Monday accepted that if he had this information available” he would have carried out the bowel procedure sooner than he did.


Dr Chris Danbury, a consultant intensivist and witness for the coroner, found that a build up of an “infection had led to sepsis”. He said Dr Gordon Pate, a consultant cardiologist and witness for the coroner, “accepted the proposition that sepsis would have been a contributory factor to death, because of the excessive demands placed on Mr Daly’s heart”.

In conclusion, Mr McNamara said that “on the balance of probabilities, which is the appropriate standard to assess this case on, I’m satisfied that the appropriate verdict to record is one of medical misadventure”.

The inquest heard the Pathologist who conducted Mr Daly’s postmortem in 2010 was not aware that he had contracted sepsis following an infection when recording the original cause of death was simply due to cardiac failure.

Mr McNamara expressed his condolences to the family and reminded all parties that his verdict “does not carry any connotations with it of blame or liability”.

Speaking afterwards, Mr Daly’s widow, Mary Daly, said: “I just want to thank everyone for their kindness for my husband, he was a kind man, we had a good life together, we were happy.

“Of course I’m delighted with the verdict, it has been a long road and thank God it is finally over now.”