Verdict of medical misadventure in Mayo man’s death

An 82-year-old man died because of the failure of authorities at Mayo General Hospital in Castlebar, to administer the anti-coagulant Octaplex in a timely manner, an inquest was told on Monday.

Dr Kenneth Power, a Liverpool based consultant in anaesthesia and intensive care, told an inquest that had Darby King from Derrynalecka in Castlebar, been anti-coagulated with appropriate speed he would have survived.

“He would not have gone back to the man he was”, Dr Power stated, “but he would have been able to survive and would have been able to appreciate his family if he had done so”.

Dr Power gave evidence at an inquest in Castlebar, conducted by Coroner John O’Dwyer, into the death of Mr King at Mayo General Hospital on April 27th last three days after the car he was driving was involved in a collision with a 4x4 at Belcarra in Castlebar.

The deceased, who sustained a small laceration to the head in the impact, told a garda at the scene he had been blinded by the sun.

Mr King’s family maintain medical personnel failed to recognise key aspects of his medical condition on admission, that he was not given the appropriate tests and examinations, and staff failed to follow hospital protocol or the advice from the neurological specialist unit in Beaumont for several hours.

After an absence of about five minutes, an inquest jury returned a verdict of medical misadventure.

Members of the King family quietly applauded when the verdict was delivered.

The coroners’ hearing was told that Mr King, the principal carer for his wife who has Alzheimers, was on the oral anti-coagulant Warfarin at the time.

Dr Power said he believed some form of stroke occurred, which caused Mr King to lose control of his car

He added that he was surprised that nobody in hospital triage noted he was on anti-coagulation medicine.

Dr Power said that authorities at Beaumont Hospital, which had been consulted about Mr King's condition, had instructed that Octaplex be administered but this had not been done until about 10.45pm when he had been in hospital for more than ten hours.

Medical experts from Beaumont Hospital told the hearing that rather than surgery, they had decided to opt for “comfort” measures.

Dr Mark Woods, neurosurgical registrar in Beaumont at the time Mr King was referred, said that no process that could have been done would have been helpful to Mr King.

Dr Darach Crimmins, consultant neuorosurgeon at Beaumont Hospital, said he decided Mr King should not have surgery for his haematoma due to his clotting problems and his poor medical condition.

“There would be no chance of any meaningful recovery,” he said. “As such, surgery although heroic, would be ultimately futile.”

Serious staffing issues at the emergency department of Mayo General Hospital were highlighted by nurses at the hearing.

The staff shortages were outlined by clinical nursing manager Jennifer Quinn and her colleague, nurse Geraldine Flannery.

Ms Flannery told the inquest that the nurse to patient ratio was not satisfactory during the time Mr King had been a patient.

The emergency department was extremely busy on the day of Mr King’s admission with over 100 patients being seen, the witness explained.

Clinical nurse manager Jennifer Quinn told the inquest in a deposition there were “several very serious staffing issues” in the emergency department in the week of April 21st, 2014.

“I brought this to the attention of nursing management on numerous occasions,” Ms Quinn, who did not attend the inquest due to illness, continued in her statement.

Caroline Murnane, daughter of the deceased, and Gerard Murnane, son-in-law, both gave evidence to the inquest in which they expressed dissatisfaction over the way he had been treated at the hospital.

Ms Murnane said she overheard an emergency department doctor checking who was checking her day, say, “This is the biggest mistake I have made all day”.

The witness said she was told her father had a bleed on the right side of his brain and there was also a collection of blood on the left side.

She then said she had to contact Beaumont Hospital straight away.

Beaumont’s advice was that nothing could be done as the bleeding was too extensive.

Mr King was removed from the ventilator and he passed away at 3.40am on April 27th.

Mrs Murnane said her father was independent and part of a large community with a wide network of friends whom he met regularly.

He was the primary carer to his wife, Teresa, who has Alzheimers.

He was also carer to his brother, Tom, who suffers with poor mobility and is only able to walk with the aid of a walking frame.

“He was a wonderful dad to us. We miss him terribly” she said. “My dad’s early passing had had a traumatic and irreversible effect on all our family.”

Barrister Marie Ahern (Callan /Tansey & co), who represented the dead man's family, said the family did not accept Mr King's death was inevitable in those circumstances.

She called for on the jury to deliver a verdict of misadventure on the grounds there had been a medical accident and that the appropriate protocol was not followed.

But Lorraine Scully, counsel for the Health Service Executive (HSE), sought a verdict of death from natural causes. There had been evidence, she said, that Mr King's health had been deteriorating all the time.