The death of a Donegal woman was linked to “a breakdown in communications” among medical staff at Letterkenny University Hospital which resulted in delays in responding to an abnormal CT scan, an inquest has heard.
A sitting of Dublin District Coroner’s Court was also informed that LUH had issued an apology to the family of the late Marion Kelly for the hospital’s failure to provide her with the appropriate standard of care.
The inquest heard it was almost 48 hours after the CT scan, which had revealed bleeding in the brain, was completed before doctors treating her were aware of its findings and realised the seriousness of the patient’s condition.
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The consultant physician responsible for Ms Kelly’s care at LUH, Amjed Khamis, admitted the outcome for the patient could have been different if doctors had been made aware of the results promptly.
Ms Kelly (64) a married mother of two of Back Street, Carrigans, Co Donegal, died at Beaumont Hospital on November 5, 2019 where she had been transferred by ambulance the previous day.
A post-mortem confirmed that she had died from a ruptured aneurysm in an artery bringing blood to the brain.
The deceased’s daughter, Donna Kelly, told the inquest that her mother had been suffering from severe headaches for around a week before she was referred to the emergency department at LUH on November 1, 2019.
The inquest heard that a CT scan was ordered at 3.54am the following morning which was a Saturday and carried out at 11.43am.
Ms Kelly said her family became very concerned that she was very confused and not eating over the weekend and had asked doctors to review her condition on November 3, 2019.
She was subsequently called the following morning to say her mother was being transferred to Beaumont Hospital after the tests of the CT scan had been analysed.
“We are very hurt and angry that the CT scan was not read in a timely manner,” said Ms Kelly.
She recalled the last words she said to her mother were: “You’re not going to die, Mam.”
Dr Khamis told the inquiry that he had examined Ms Kelly, who was on a trolley as the hospital was overcrowded at the time, at around 9.45am on November 2, 2019.
The consultant said he was aware a CT scan had been ordered for the patient but he had not been alerted to its results by the time he left the hospital at 2pm.
As he had not been contacted about them, he presumed there had been “non-significant findings” from the scan.
Dr Khamis said he was “shocked” when he found out about the findings of the CT scan when he returned to the hospital on the following Monday morning as it was an emergency case.
The consultant said there were “absolutely” better communications in relation to the handover of patients at weekends now.
Dr Khamis told counsel for Ms Kelly’s family, Doireann O’Mahony BL, that he did not know why she had been transferred to a gynaecological ward but that it was “not unusual…if not ideal.”
The consultant radiologist who carried out the CT scan, Vladimir Koruncev, said he had tried calling LUH’s emergency department a number of times once he had the results but he was unable to establish which consultant was responsible for Ms Kelly or where the patient was located.
Dr Koruncev said the hospital was very busy and overcrowded at the time with over 50 patients and he had a lot of other duties.
He told the coroner that he would have called Dr Khamis if he had known he was responsible for Ms Kelly but noted the hospital had “no clear communications strategy.”
The radiologist said he had presumed the results, which had recommended that Ms Kelly be reviewed by a consultant neurologist, had been read by one of the medical team looking after the patient.
Dr Koruncev admitted he felt personal responsibility and guilt about what happened but stressed there was also “a huge failure with the system.”
A consultant neurologist at Beaumont Hospital, Stephen McNally, said Ms Kelly had to be intubated en route from Letterkenny after suffering what was now known to be a third profound bleed in the brain.
Dr McNally said it was an unusual case as up to 80% of patients already die if they have a second bleed to the brain.
The consultant said it was unknown when Ms Kelly suffered the first bleed but it could have occurred when she first reported severe headaches. It is believed she suffered a second bleed on the morning of November 4, 2019.
He told the coroner, Cróna Gallagher, that he would have recommended the patient’s transfer to Beaumont on the basis of the results of her first CT scan on November 2, 2019.
The inquest heard that approximately 1 in 3 patients who suffer a bleed to the brain die but the possibility of a second bleed could be prevented in up to 90% of survivors.
However, Dr McNally said patients who suffered a third bleed were effectively “unsalvageable.”
Counsel for LUH, Luán Ó Braonáin SC, acknowledged that there had been shortcomings in the care provided to Ms Kelly by the hospital which had resulted in “tragic consequences.”
Mr Ó Braonáin said the hospital was introducing improvements for alerting medical staff to critical test results.
He also stated at the outset of the hearing that LUH would not oppose any submission by Ms Kelly’s family seeking a verdict of medical misadventure.
Counsel for the Kelly family, Miriam Reilly, SC, said her clients had been comforted by the hospital’s approach to the inquest.
Ms Reilly said there had been “significant learnings” from Ms Kelly’s death for LUH including new draft guidelines for how radiologists should alert other medical staff to critical findings from scans which she noted were at an advanced stage.
Dr Gallagher acknowledged that under the new draft guidelines a consultant radiologist would be required to verbally notify the clinician responsible for the patient of a critical finding within 60 minutes of getting the test results.
Returning a verdict of medical misadventure, the coroner said she would endorse the proposed changes being made at the hospital.
In order to prevent future deaths, Dr Gallagher said she would also issue a recommendation for enhanced and ongoing mandatory training for staff involved in electronic and verbal communications of critical test results.
The coroner said she would particularly recommend the formalising of clinical handover procedures during out-of-hours and weekend periods to cover time-sensitive and critical tests.
Speaking after the ruling, the family’s solicitor, Jolene McElhinney, said her clients were very grateful that they had got a lot of answers from the inquest.
“Although they welcome the apology from the hospital, they are dismayed that it took so long,” said Ms McElhinney.
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