Woman died due to medical misadventure, inquest finds

Coroner hears doctor was contacted four times over concerns about Marian Tracy (60)

A verdict of medical misadventure has been returned at the inquest into the death of Marian Tracy (60).

Ms Tracy, of Dodsboro Road, Lucan, Co Dublin, died in St James's Hospital four days after surgery to remove her thyroid was performed there on May 14th, 2015.

She died as a result of a lack of oxygen to the brain due to the compression of the windpipe by a clot following the thyroidectomy surgery.

Ms Tracy developed neck swelling and difficulty swallowing and breathing the day after her surgery, the inquest at Dublin Coroner’s Court had heard.


ENT (ear, nose and throat) registrar-on-call Dr Monica Istovan was contacted four times between 6.30pm and 11.04pm on May 15th, 2015, by hospital staff and an intern doctor relaying concerns for the patient.

However, the registrar-on-call did not visit Ms Tracy in hospital until after she had suffered a respiratory arrest on the same date, the court was told.

Ms Tracy died three days later on May 18th.

Concluding a two-day inquest into Ms Tracy's death, Coroner Dr Myra Cullinane recommended that St James's Hospital and the HSE review their policy of consultants operating on-call services for multiple hospitals and consider having senior on-call staff on-site at the hospitals.

The Coroner recommended that hospital staff across all levels be enabled to contact senior staff directly and that neck swelling post-thyroid surgery prompt early review by ENT staff.

Family statement

In a statement read out after the inquest, the Tracy family said they were devastated by Marian’s loss.

“Marian was the heart of our family and her death has left a huge void in all our lives.

“We would hope that Marian’s death wasn’t in vain and [that] the Coroner’s recommendations be put in place and hopefully prevent another family having to suffer as we have.”