An inquest had heard that there was a dispute between a doctor and nurse at a Dublin hospital over whether a tube providing oxygen had become dislodged during an incident in which a patient being treated for meningitis suffered a fatal lack of oxygen to the brain.
Tommy Walsh (59), a married father of two from Laurel Lodge, Castleknock, Co Dublin, was confirmed as having bacterial meningitis after being admitted to Connolly Hospital Blanchardstown on February 23rd, 2019 by ambulance after complaining of headaches and flu-like symptoms.
A sitting of Dublin District Coroner’s Court heard that Mr Walsh died on March 2nd, 2019 as a result of brain injury caused by a lack of oxygen suffered on the day after his admission to the hospital.
The coroner, Cróna Gallagher, returned a verdict of medical misadventure after hearing evidence that the patient’s death was linked to the problems with his endotracheal tube.
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The inquest on Monday heard that the deceased had suddenly become agitated while intubated and ventilated under sedation in an isolation room of the hospital’s intensive care unit in the early hours of February 24th, 2019 when he appeared to dislodge the tube.
A clinical nurse manager, Rosanne Kenny, told the hearing that she had twice expressed concern to a registrar anaesthetist, Ilankathir Sathivel, that the tube was not correctly in place.
Ms Kenny said Dr Sathivel had twice replied that he believed the tube was in place and did so “in a raised voice” on the second occasion.
The nurse said she first noticed that the tube had become dislodged by about two centimetres when she was called urgently into the isolation room shortly before 4am.
She recalled that the ventilation alarms were going off which indicated that the patient was not receiving oxygen.
Ms Kenny said she subsequently raised her concerns about the management of the tube at a debriefing while an external review was also carried out into the incident.
She told the coroner that the dislodgement of such tubes can occur as every patient is unpredictable.
Ms Kenny agreed with counsel for Mr Walsh’s family, David McParland BL, that it was “a very distressing incident”.
In evidence, Dr Sathivel accepted that the tube could have been dislodged but stressed that at the time he believed it had been in place.
“It was a crisis situation which puts a lot of pressure on everyone,” he remarked.
Dr Sathivel said he was trying to restore oxygen saturation to the patient as soon as possible and was concerned that the tube might have been blocked by the patient’s vomiting.
He recalled seeing the patient breathing with the tube in place.
He said he had earlier instructed staff to sedate Mr Walsh to stop any agitation he might be experiencing from headaches.
The registrar said he had never told any nurse to lower the patient’s level of sedation.
The inquest heard Mr Walsh suffered a cardiac arrest at around 4.15am and started experiencing seizures over an hour later.
A consultant endocrinologist at the hospital, Tommy, Kyaw-Tun, said he would have expected a patient of Mr Walsh’s age and condition with meningitis to survive generally.
Dr Kyaw-Tun told the coroner that it was not uncommon for someone who had a cardiac arrest to suffer brain injury.
The consultant said he believed Mr Walsh had suffered a cardiac arrest due to his low oxygen level at the time.
The deceased’s wife, Liz Walsh, said her husband – an employee of the Road Safety Authority – had been physically well and active prior to becoming ill shortly before his death.
She said she was shocked at what happened on his first night in the hospital and believed the situation could have been “more under control”.
Ms Walsh said she was informed by hospital staff that her husband would be expected to recover from the illness.
A postmortem showed the deceased had chronic heart and lung disease and swelling on the brain.
Returning a verdict of medical misadventure, Dr Gallagher said Mr Walsh had died as a result of lack of oxygen to the brain with meningitis as a contributory factor.
The coroner said the verdict was not seeking to blame anyone but to reflect the fact that his death was the unintended outcome of an act or omission during medical treatment.