An internal review has been carried out and an apology made to the family of a 74-year-old patient whose body was released from hospital without a directed coroner’s postmortem taking place, an inquest has heard.
A sitting of Dublin District Coroner’s Court on Thursday heard that the death of Olive Doyle on November 4th, 2023, was appropriately referred to the coroner’s court as it was sudden and unexpected.
Ms Doyle from Bray, Co Wicklow had been admitted to St Vincent’s University Hospital on October 13th suffering from malignant melanoma, alongside several other conditions including chronic obstructive pulmonary disease, and asthma.
Other medical conditions and complications arose throughout her stay as a result of her immunotherapy treatment including multiple toxicities which ultimately contributed to her death.
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Ms Doyle remained an inpatient until her death, the medical cause of which was recorded as pneumonia and infective COPD exacerbation due to severe multiple steroid refractory immunotherapy toxicities.
Coroner Aisling Gannon said there was a “miscommunication” among staff at the hospital where they misunderstood that no postmortem was required and released Ms Doyle’s body to her family.
Ms Gannon told family members that St Vincent’s has since carried out an incident investigation review, “and it has been noted that this should not have happened”.
A staff member from St Vincent’s hospital who was engaging with the Coroner’s Court on the issue was not available to attend the inquest on Thursday but assured the coroner that it would not happen again.
The staff member apologised on behalf of the hospital for the communication issues which resulted in Ms Doyle’s body being released without a postmortem.
“I’m conscious there is a dearth of information available to us and I’m conscious that regrettably isn’t going to change,” Ms Gannon told family members present.
Ms Gannon said it was unusual to have requested and directed a postmortem and not have it available, however added that inquests often proceed without such, particularly when medical records are available.
Representing Ms Doyle’s family, barrister Eavanna Fitzgerald said despite the family being left with “many unanswered questions”, they did not wish to enter into any “adversarial situation either today or in the future”.
“Olive was a placid person who would not have wanted that,” she said.
Ms Fitzgerald said Ms Doyle’s family was “heartbroken” at her sudden loss, describing her as “lovable and a very positive person who had great empathy”.
The inquest heard how Ms Doyle’s admitting consultant, Dr Yasar Ahmed, believed the potential benefits of immunotherapy outweighed the risks posed to Ms Doyle, despite her pre-existing conditions though he said he was surprised at the extent of the complications.
Dr Ahmed said severe reactions such as that of Ms Doyle affect between 9 to 10 per cent of patients and usually occur over several weeks rather than days.
He said it was a “rare but recognised” response which only occurs in approximately 1 per cent of patients.
Ms Fitzgerald raised several concerns on behalf of the family, namely a lack of communication throughout her inpatient stay, saying they had not been informed of Ms Doyle’s cardiac arrest which occurred hours before her death.
Although on leave in the immediate days leading up to her death, Dr Ahmed apologised on behalf of clinicians present at the time for any lack of communication which would have prepared the family for Ms Doyle’s death.
They also questioned why Ms Doyle had been moved seven times over the 23 days, to which Dr Ahmed shared their frustration saying medical staff have no role in the movement of patients.
Ms Fitzgerald also said family was not fully aware of the implications of supporting Ms Doyle’s decision not to enter the intensive care unit after deteriorating.
Ms Gannon said a short narrative verdict would be returned and shared with the family at a later date.
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