Medical view/Dr Muiris Houston: The death of Patrick Joseph Walsh at Monaghan hospital last week from a gastrointestinal haemorrhage has raised a number of clinical and ethical questions.
Mr Walsh was known to have a peptic ulcer, which is a raw area or small hole in the lining of the stomach or the duodenum (the first part of the small intestine). Most ulcers occur in the duodenum (duodenal ulcers); a smaller number develop in the stomach and are known as gastric ulcers.
Peptic ulceration occurs when acid and an enzyme called pepsin erode the lining of the stomach or duodenum. The bacterium Helicobacter pylori is the causative agent in most peptic ulcers.
Up to 20 per cent of patients with peptic ulcers develop bleeding from the ulcer. It is a serious complication with 80 per cent of deaths from ulcers in older people attributable to an episode of acute haemorrhage.
Mr Walsh's age (75) and the fact that he had already bled from the ulcer while an inpatient in Our Lady of Lourdes Hospital, Drogheda, meant that he was at high risk of dying from the bleed that subsequently occurred at Monaghan General Hospital.
These risk factors were also the reason why, ideally, he should have been admitted to an intensive care unit (ICU).
Most people with bleeding from a gastric or duodenal ulcer are successfully treated using an endoscope to deliver the thermal energy needed to get the bleeding vessel to clot. A flexible tube with a light source, the endoscope is used to apply either direct cautery or heater probe therapy to the area of bleeding.
Endoscopy is initially successful in more than 95 per cent of cases. However, rebleeding occurs in about 25 per cent of patients. Surgery is needed in less than 10 per cent of people with bleeding ulcers.
The inquiry into Mr Walsh's death by Belfast consultant surgeon Declan Carey, is likely to seek answers to the following questions: (a) Could he have been treated medically using an endoscope at Monaghan rather than seeking surgical treatment at another hospital in the region?
(b) If surgery was considered the best intervention, why was Mr Walsh not transferred to Cavan or Drogheda and in the absence of an ICU bed, managed in the immediate post operative period in theatre?
(c) At what level of seniority did clinical communication about Mr Walsh take place? Was there a systems failure?
(d) Was the ethical imperative and duty of care for a doctor to assist an acutely ill patient to the best of his ability interfered with by the health service directive that no emergency surgery take place in Monaghan after 5pm?