Woman died of sepsis after hernia operation, inquest told

A woman who died of sepsis after developing an “extremely rare” infection “had everything to live for” after losing eight stone for an operation, her daughter has said.

Melissa Barry was speaking after the Dublin coroner returned a verdict of medical misadventure at the inquest into the death of Susan McGee (52), from Skerries Road in Rush, Co Dublin.

The mother-of-two died at Beaumont Hospital on July 24th, 2013, having developed a rare Clostridium difficile infection affecting almost her entire bowel following a hernia operation at the Hermitage Medical Clinic 11 days earlier.

The inquest heard from consultant surgeon Prof Arnold Hill that during the hernia operation, a superficial outer colon tear was repaired and, as a result, Ms McGee was placed on a longer course of antibiotics.

One of the risk factors for developing C Diff infection is the use of antibiotics.

Returning the verdict, coroner Dr Brian Farrell said C Diff normally causes diarrhoea, but in this case it resulted in an “extremely rare” severe enterocolitis – inflammation of the digestive tract.

Multi-organ failure

She went into multi-organ failure after developing sepsis, secondary to the enterocolitis caused by the C Diff infection.

One of the issues exercising the family’s legal team at the inquest was the handover of Ms McGee’s care when Prof Hill went on leave three days after her readmission to the Hermitage with a small bowel obstruction.

He said he anticipated a “prompt” recovery when he handed care from Saturday, July 20th, 2013 onwards to his colleague, consultant general surgeon Colm Power.

However, Mr Power was not aware surgical registrar Dr Firas Ayoub could only review Ms McGee on Saturday.

Mr Power left instructions he should be called if there was any deterioration in Ms McGee’s condition.

When her blood pressure dropped on Sunday evening, the resident medical officer on call was called instead.

He consulted with Dr Ayoub rather than Mr Power. She was first seen by Mr Power the following morning after he was told of her overnight deterioration.

Summing up, Dr Farrell said the reporting structures following handover were not clear to some of the nurses “and even the consultants”.

Counsel representing the Hermitage, Conor Halpin said it is “quite clear that it was set out in the medical notes” who was to be contacted and had responsibility for Ms McGee’s care over that weekend. The Hermitage has since expanded on its handover protocol, he said.

‘Fail-safe handover’

Following the verdict, the family’s solicitor Dermot McNamara said the case “highlights the need for a fail-safe handover protocol between consultants, in both the private and public sector”.

“Patients need to be assured that details of their medical condition and care plan are properly communicated if they are being put into the hands of different medical professionals,” he said.

Speaking outside the court, Ms Barry said the inquest had been difficult, but answered a lot of the family’s questions.

She described her mother as a “bubbly, outgoing person” who “idolised” her family and “lived for her grandkids”.

“She was living for her family. She worked in the family business, she got on with everyone. She never had a bad word to say about anybody,” she said.

Ms McGee lost eight stone in less than a year before the hernia operation.

“She wanted to be able to play football with her grandson… After losing the eight stone, she had everything to live for,” her daughter said.