A mum bled to death in hospital after a “systems failure” in her care, an inquest heard yesterday.
Susan Doherty, 47, died eight days after being rushed to hospital with a sore throat, high temperature and low level of white blood cells.
Doctors had requested an “urgent” scan after she complained of severe chest pain, but it was not followed up and she died after suffering a massive bleed to her spleen, an inquest heard.
She did not receive the CT scan until almost 24 hours later but by this time she had suffered a cardiac arrest, reports the Irish Mirror.
Ms Doherty died at the University Hospital Limerick (UHL) in Ireland on July 4, 2020, eight days after arriving at the ward.
UL Hospitals Group apologised to Ms Doherty's family following the tragedy.
She had arrived at UHL with a medical history of rheumatoid arthritis and autoimmune neutropenia - a blood disorder where the immune system attacks white blood cells.
Senior Counsel for ULH Group Conor Halpin read a letter of unreversed apology at her inquest, which was signed by COO Noreen Spillane.
It read: "I apologise unreservedly for the sorrow and distress caused to you and your family over Susan’s untimely death and for the personal trauma experienced by you and your family."
Some 11 recommendations were made following an internal review but they are yet to be implemented.
Retired senior nurse manager Mary McKiernan said Ms Doherty was not monitored as per protocol and the patient’s ward was “short staffed”.
It was also said that there was delay in weekend rostered on-call consultants being made aware of her condition.
Ms Doherty was prescribed heparin after it was suspected her abdomen pain was due to a blood clot in her lung.
An “urgent” CTPA, or pulmonary angiogram, was prioritised over the CT scan of her abdomen and pelvis.
Her condition further deteriorated and she needed a bed in the high dependency unit but none were immediately available.
She suffered a cardiac arrest just after midnight on July 4 and was transferred to ICU after doctors resuscitated her.
Scans were not carried out until around 5am.
The CTPA which had been prioritised over the CT scan was negative while the CT scan confirmed a major haemorrhage in her spleen.
Ms Doherty underwent emergency surgery to remove the ruptured spleen, but was pronounced dead around midday on July 4.
Coroner John McNamara recorded a verdict of “medical misadventure” but found there was no evidence of any wrongdoing by anyone involved in Ms Doherty’s care.
