Recommendations that followed man's death not passed on to hospital staff

A coroner has expressed "alarm" that recommendations of an internal review by the Health Service Executive (HSE) into the death of a 79- year-old-man in intensive care in Mayo General Hospital were not communicated to medical staff.

Complaints by the family of Patrick Gannon of Kilsallagh, Westport, precipitated the “incident review” by the HSE after he died on March 10th last of acute obstructive cholangitis, a type of bacterial infection, that was complicated by sepsis.

The findings of the HSE internal review, which was received by the Gannon family on August 28th last after a number of requests, were heard by south Mayo coroner John O’Dwyer at Monday’s inquest into Mr Gannon’s death.

The review noted that within 24 hours of presenting to Mayo General Hospital, Mr Gannon had been reviewed by nine doctors on more than 10 occasions.

It recommended that when various teams were involved in the care of one patient an emergency response system should be in place to ensure care is discussed and co-ordinated by the admitting team with other team members, so that a “holistic” plan of care can be agreed.

Mr Gannon was admitted to hospital on March 8th last with what the family believed to be a stomach bug, and which was identified as a gallstone. His wife, Margaret, had initially brought him to a GP as she noticed he was a little nauseous. Mr Gannon had heart disease and respiratory problems.

When the family came back into the hospital the following morning, they were told Mr Gannon was “very unwell” and the intern, Dr Julianne O’Shea, said the intravenous drip she had administered “went too fast” and that “she had not been aware of his pulmonary fibrosis until afterwards when she read his medical chart”.

Expert witness Dr Shallandrea Daivajna said that he had attended Mr Gannon on the evening of March 9th, and found him to be responding to the ongoing treatment.

However, he was contacted again at 10.38pm by the cardiac arrest team. After cardiopulmonary resuscitation, Mr Gannon was transferred to the intensive care unit. Mr Gannon died at 12.11am on Sunday, March 10th, two days after admission.

Expert witness Dr Cyril Rooney said he had used a multidisciplinary approach but was “surprised Mr Gannon deteriorated so quickly”.

Mr Gannon’s daughter Caitriona asked expert witnesses at the inquest why her father had not been transferred to the intensive care unit earlier. She welcomed the fact that the HSE review included recommendations that would ensure a more “holistic” approach was used for patients in the future.

However, Mr O’Dwyer confirmed last night that he was concerned Dr Rooney had not been made aware of the review and its recommendations. Mr O’Dwyer asked what was the point of the HSE conducting the report if “those involved are not privy to it” , and whose responsibility it was to implement the review recommendations.