A woman died after a routine biopsy pierced a swollen blood vessel in a lump in her windpipe, an inquest has heard.
Marian O'Reilly (76), of Fordstown, Navan, Co Meath, died within three hours of the biopsy on February 2nd, 2015, despite the best efforts of medics to save her, Dublin Coroner's Court heard.
The court heard there was only one other similar case documented in the world.
Ms O’Reilly, who had surgery at the age of 12 in 1951 to remove half of her left lung, had been suffering frequent respiratory infections, the court heard.
She underwent a biopsy without event in 2012, but as the infections became more frequent towards the end of 2014, she was referred to Bons Secours for a bronchoscopy, a procedure used to examine the inside of the lungs.
During the bronchoscopy, doctors noted that a polyp in her windpipe had grown and a biopsy was taken to check if it was malignant.
However, during the procedure, the polyp began to bleed uncontrollably, leading to the woman’s death two-and-a-half hours later.
"I have done 30,000 of these [biopsies] and never seen this before," said Prof Conor Burke, the respiratory consultant at the Bons Secours hospital in Dublin.
Postmortem
A postmortem carried out by pathologist Dr Jane Thorne found the woman died due to catastrophic intra-pulmonary haemorrhage, secondary to a biopsy on an ectatic large artery at the point where the biopsy was sampled.
The inquest found the blood vessel was located unusually close to the mucous membrane surface of the lump in the woman’s windpipe and the biopsy opened the blood vessel, resulting in profuse bleeding.
"The location of that type of blood vessel was unusual and it bled profusely," Coroner Dr Myra Cullinane said.
“It’s clear this is an exceptionally rare occurrence, with only one other similar case recorded in world literature,” Dr Cullinane said.
Returning a verdict of medical misadventure, the Coroner extended her sympathies to the woman’s family.
“This is obviously something that was entirely unexpected, particularly when she had many years of dealing with respiratory issues, it’s the last thing I imagine you expected to hear that day,” the Coroner said.