A communication breakdown at James Connolly Memorial Hospital, Dublin, led to a woman suffering with cerebral palsy not being fed for three days, an inquest has heard.
Michelle Tallon (38), Kilcock, Co Kildare, died at the hospital of acute respiratory distress syndrome (ARDS) on July 23rd last year, 2½ weeks after she was admitted.
A jury at the inquest returned a verdict of death by medical misadventure and recommended the hospital set up a team to deal specifically with patients with special needs. They also recommended the hospital improve their communications protocol.
An internal investigation following Ms Tallon's death revealed a number of systems failures at the hospital, coroner Dr Kieran Geraghty told the court.
The inquest heard that Ms Tallon, who was unable to speak or feed herself, was initially admitted complaining of constipation and of vomiting. She also had trouble keeping anything down.
Doctors initially believed she was suffering from a gastro-intestinal infection. Initial instructions by doctors were that Ms Tallon should not be fed but she did receive fluids and nutrients through a drip.
Four days after admittance, medical staff decided that she could begin to take solids again but failed to remove an NPO (nil per oral) order from her bedside, which indicated to nursing staff that the patient was not to be fed. While medical staff gave verbal instructions to withdraw the NPO orders, this also was not documented in the clinical record, the inquest heard.
Dr Edward Keelan said the instructions of the medical team were that Ms Tallon was to begin eating solids on July 11th but "some confusion" led to this message not getting through to the nursing team until July 13th.
In the week following the mix-up, Ms Tallon suffered an acute deterioration and died a few days later.