Death of Donegal woman linked to ‘breakdown in communications’ at Letterkenny University Hospital
Posted on 15th March 2023 at 13:06
The death of a Donegal woman was linked to “a breakdown in communications” among medical staff at Letterkenny University Hospital which resulted in delays in responding to an abnormal CT scan, an inquest has heard.
A sitting of Dublin District Coroner’s Court was also informed that LUH had issued an apology to the family of the late Marion Kelly for the hospital’s failure to provide her with the appropriate standard of care.
The inquest heard it was almost 48 hours after the CT scan, which had revealed bleeding in the brain, was completed before doctors treating her were aware of its findings and realised the seriousness of the patient’s condition.
The consultant physician responsible for Ms Kelly’s care at LUH, Amjed Khamis, admitted the outcome for the patient could have been different if doctors had been made aware of the results promptly.
Ms Kelly (64) a married mother of two of Back Street, Carrigans, Co Donegal, died at Beaumont Hospital on November 5th, 2019, where she had been transferred by ambulance the previous day.
A post-mortem confirmed that she had died from a ruptured aneurysm in an artery bringing blood to the brain.
The deceased’s daughter, Donna Kelly, told the inquest that her mother had been suffering from severe headaches for around a week before she was referred to the emergency department at LUH on November 1st, 2019.
The inquest heard that a CT scan was ordered at 3.54am the following morning which was a Saturday and carried out at 11.43am.
Ms Kelly said her family became very concerned that she was very confused and not eating over the weekend and had asked doctors to review her condition on November 3, 2019.
She was subsequently called the following morning to say her mother was being transferred to Beaumont Hospital after the tests of the CT scan had been analysed.
“We are very hurt and angry that the CT scan was not read in a timely manner,” said Ms Kelly.
She recalled the last words she said to her mother were: “You’re not going to die, mam.”
Dr Khamis told the inquiry that he had examined Ms Kelly, who was on a trolley as the hospital was overcrowded at the time, at around 9.45am on November 2nd, 2019.
The consultant said he was aware a CT scan had been ordered for the patient but he had not been alerted to its results by the time he left the hospital at 2pm. As he had not been contacted about them, he presumed there had been “non-significant findings” from the scan.
Dr Khamis said he was “shocked” when he found out about the findings of the CT scan when he returned to the hospital on the following Monday morning as it was an emergency case.
The consultant said there were “absolutely” better communications in relation to the handover of patients at weekends now.
The consultant radiologist who carried out the CT scan, Vladimir Koruncev, said he had tried calling LUH’s emergency department a number of times once he had the results but he was unable to establish which consultant was responsible for Ms Kelly or where the patient was located.
Counsel for LUH, Luán Ó Braonáin SC, acknowledged that there had been shortcomings in the care provided to Ms Kelly by the hospital which had resulted in “tragic consequences.”
Counsel for the Kelly family, Miriam Reilly, SC, said her clients had been comforted by the hospital’s approach to the inquest.
Ms Reilly said there had been “significant learnings” from Ms Kelly’s death for LUH including new draft guidelines for how radiologists should alert other medical staff to critical findings from scans which she noted were at an advanced stage.
Coroner Dr Cróna Gallagher acknowledged that under the new draft guidelines, a consultant radiologist would be required to verbally notify the clinician responsible for the patient of a critical finding within 60 minutes of getting the test results.
Returning a verdict of medical misadventure, the coroner said she would endorse the proposed changes being made at the hospital.
In order to prevent future deaths, Dr Gallagher said she would also issue a recommendation for enhanced and ongoing mandatory training for staff involved in electronic and verbal communications of critical test results.
The coroner said she would particularly recommend the formalising of clinical handover procedures during out-of-hours and weekend periods to cover time-sensitive and critical tests.
Speaking after the ruling, the family’s solicitor, Jolene McElhinney, said her clients were very grateful that they had got a lot of answers from the inquest.
“Although they welcome the apology from the hospital, they are dismayed that it took so long,” said Ms McElhinney.
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