AN INQUEST into the death of a woman following an elective procedure to remove gallstones heard there was a delay in diagnosing her with severe acute inflammation of the pancreas.
Mary Dolan (81), of Brackloon, Castleplunkett, Castlerea, Co Roscommon, died at St James’s Hospital in Dublin on February 20th, 2009, after developing acute pancreatitis or inflammation of the pancreas.
The pancreatitis was a complication of a procedure, endoscopic retrograde cholangiopancreatography (ERCP), to remove gallstones from her bile duct, which Ms Dolan underwent at the hospital in January.
Dublin City Coroner’s Court heard results of a test after the ERCP showed an elevated level of the serum amylase enzyme at “30 times the upper limit of normal”. The results were available for medical personnel to view on the hospital system on January 17th, but were not seen.
Ms Dolan was diagnosed with acute pancreatitis on January 19th.
Coroner Dr Brian Farrell told the inquest that “clearly” such a level of amylase “would establish a severe acute pancreatitis”. “I regret to say there was a delay in making the diagnosis,” he said.
“Had the diagnosis been made on the 17th, it would have had a bearing on the subsequent medical treatment,” he added.
“One cannot say what the outcome might have been . . . but it was recognised it would have required a different approach,” perhaps a transfer to intensive care, he said.
“This constitutes another significant risk factor,” he said.
The inquest heard Ms Dolan had undergone a difficult, prolonged procedure to remove gallstones on January 16th.
She had abdominal discomfort the following morning, and a serum amalyse test was ordered.
Giving evidence on an earlier date, Dr Anna Walsh, who reviewed Ms Dolan, told the inquest she found it “highly unusual” that a high level of amalyse was on the system and she did not see it.
Abnormal results are flagged in red on the computer system.
A postmortem found Ms Dolan died of septic shock due to E-coli septicaemia, a complication arising out of acute pancreatitis, following an elective procedure to remove gallstones.
Dr Farrell said he would record a verdict of death by medical misadventure.
“There was a delay in making the diagnosis of post-procedure acute pancreatitis,” he said.
He expressed his condolences to Ms Dolan’s son and three daughters, who were in court yesterday.
Speaking outside the court after the hearing, her son, Brian Dolan, said the family was satisfied with the outcome of the inquest.