Medical misadventure resulted in the death of a woman who was wrongly diagnosed by doctors, Cork Coroner's Court heard yesterday.
Catherine McCarthy died following a catalogue of incidents while being treated at Cork University Hospital (CUH).
Ms McCarthy went to CUH's Accident and Emergency department on March 20th this year, complaining of severe pains in her stomach.
The 42-year-old mother of two died on March 21st from a massive heart attack after vomiting up blood and faeces.
She had an undiagnosed perforated ulcer despite the fact that clear signs of the condition showed up on an X-ray.
However, neither an experienced radiologist nor the consultant treating Ms McCarthy studied this X-ray. The consultant only received the information after Ms McCarthy had died.
The conclusion of the A&E doctor was that she was suffering from severe constipation.
The court was told that the woman was transferred to a consultant haematologist the day before she died but that he had not been informed of the transfer.
In her report, the assistant state pathologist, Dr Margaret Bolster, said Ms McCarthy died from a severe duodenal ulcer which had perforated or torn and caused peritonitis.
There were hard faeces in the woman's stomach.
Dr Bolster said the development of the acute ulcer had occurred over a period of days and weeks.
Solicitor for the family of Ms McCarthy, Ernest Cantillon, said nursing notes for a period on March 21st, the day the woman died, have gone missing.
"These notes have been taken and they have been taken in highly suspicious circumstances," he said.
Mr Cantillon said the matter had been raised with the gardaí, and an investigation was under way.
The jury returned a verdict of death by medical misadventure.
They also issued recommendations that both the patient admissions policy and X-ray examination procedures be reviewed at the Cork hospital.
