A YOUNG mother bled to death following a “systems failure” in her care while she was an inpatient at University Hospital Limerick, the woman’s inquest heard on Monday.
Coroner John McNamara recorded a verdict of “medical misadventure”, but said there was no evidence of any wrongdoing by anyone involved in the care of Susan Doherty (47).
The UL Hospitals Group issued an unreserved apology to the family of Ms Doherty, who died in UHL on July 4, 2020, eight days after she presented there with a low white blood cell count, sore throat, and high temperature.
Doctors requested an “urgent” scan of Ms Doherty’s abdomen and pelvis after she complained of severe pain in her chest, but this was not followed up on, and she died after suffering a massive bleed to her spleen.
Ms Doherty presented at UHL with a medical history of rheumatoid arthritis and autoimmune neutropenia – a blood disorder where the immune system attacks white blood cells that fight infection. She had been routinely receiving the therapeutic GCSF, which carries a “very rare” risk of splenic rupture, it was heard.
By the time she received the “urgent” CT scan nearly 24 hours later, she had suffered a cardiac arrest.
Ms Doherty died around midday on July 4 shortly after undergoing surgery to remove her ruptured spleen.
Conor Halpin, Senior Counsel, acting on behalf of the UL Hospitals Group, expressed his “deepest sympathies to Susan’s family” and read out a letter of unreversed apology which was signed by Noreen Spillane, chief operations officer, UL Hospitals Group.
“Patients and their families put their trust in hospitals and in healthcare professionals and on this occasion we have fallen far short of the standards of care expected,” Ms Spillane wrote.
“I wish to apologise sincerely and unreservedly for the sorrow and distress caused to you and your family over Susan’s untimely death and for the personal trauma experienced by you and your family.”
Ms Spillane concluded: “Valuable lessons have been learnt by the Hospital and its staff”.
Eleven recommendations were made following an internal review by the hospital group, but these have yet to be implemented.
On July 2, 2020, after having showing signs of improvement Ms Doherty complained of significant pain in her abdomen as well as nausea.
Around 9am on July 3, her condition deteriorated and doctors ordered an “urgent” CT scan of her abdomen and pelvis but she was sent back to her ward after a problem was incurred accessing a cannula.
The scan was never followed up by members of her care team.
Mary McKiernan, a senior nurse manager, who has since retired, said Ms Doherty was not monitored as per the hospital’s protocols and that the patient’s ward was “short-staffed”.
Ms McKiernan said she “pushed” for Ms Doherty to receive an urgent CT scan.
There was delay in weekend rostered on-call consultants being made aware of Ms Doherty’s condition, it was heard.
Ms McKieran said she was not aware of any system that would ensure urgent scans were followed up on.
Ms Doherty was prescribed the drug heparin after it was suspected her abdomen pain was due to a blood clot in her lung.
An “urgent” CTPA (pulmonary angiogram) was requested and prioritised over the CT scan of her abdomen and pelvis.
Ms Doherty’s condition further deteriorated and it was determined she required a bed in the High Dependency Unit (HDU) for seriously ill patients, but none were immediately available.
Ms Doherty suffered a cardiac arrest at five minutes past midnight on July 4, she was transferred to the Intensive Care Unit after doctors successfully resuscitated her.
Scans were not carried out until around 5am; the CTPA, which had been prioritised over the CT scan, was negative and the CT scan confirmed a major haemorrhage in Ms Doherty’s spleen.
She underwent emergency surgery to remove the ruptured spleen, but was pronounced dead around midday on July 4.
The inquest heard that prior to being admitted to UHL, Ms Doherty had regularly been receiving the therapeutic GCSF for neutropenia, which carries an extremely rare risk of splenic rupture.
After she was admitted to the hospital she received the drug heparin, which is used in the treatment of blood clots, and which may have exacerbated her internal bleeding.
Coroner John McNamara said it appeared that a conflict between clinicians working on the frontline of the hospital and capacity and access issues were at the heart of Ms Doherty’s tragic death.
He said if a CT scan had been performed on her earlier, “it would have without any shadow of a doubt changed the trajectory of Susan’s treatment and eradicated doctors’ concerns (about a lung blood clot)”.
Mr McNamara said it appeared that, without a CT scan, doctors were “fighting with one hand tied behind their backs”.
He said an autopsy concluded that cause of death was due to “shock intra-abdominal haemorrhage, due to splenic rupture” and there was no evidence of any wrongdoing by any members of Ms Doherty’s care team.
Intensive Care Consultant at UHL, Dr Catherine Nix, told the inquest that doctors in the US were using handheld “bedside” scans to fast-track diagnosis in their patients and that this technology should be used more often in UHL and other Irish hospitals.
Mr McNamara recommenced the HSE and the UL Hospitals Group consider increased use of these scan devices.
Ms Doherty’s husband, Roland Doherty, represented by Sara Antonioni BL, instructed by Rachael Liston of Liston Flavin solicitors, Cork, said: “It’s not going to bring Susan back, but the HSE accepted there were major failings.”
“They need to change their systems to ensure this doesn’t happen again, I don’t want anyone else to go through what I have been through for the last two years.”
Paying tribute to his late wife, Mr Doherty said: “She always had a smile on her face no matter what, and she adored the ground our beautiful daughter Charlotte Rose (now aged 5) walked on, but she only had two years with her.”