Inquest finds medical misadventure where lady dies from internal bleeding in Limerick Hospital due to delay identifying splenic rupture.

Susan Doherty had a history of rheumatoid arthritis and autoimmune neutropenia.  On 26 June 2020, 47-year-old Susan attended at the Accident & Emergency Department of University Hospital Limerick with a fever and a sore throat.  It was considered that she was suffering from pharyngitis with febrile neutropenia and was treated with a drug known as G-CSF and intravenous antibiotics.  Importantly, a rare side effect of G-CSF is splenic haemorrhage or rupture.

Susan remained in hospital and on 2 July 2020 Susan developed persistent and severe abdominal, epigastric and back pain with vomiting, tachycardia, pallor, hypotension, fainting, new onset anaemia (Hb level noted as 8.5 on 2 July 2020) and significant abdominal tenderness.  Susan’s husband was called by the nursing staff to see her on the evening of 2 July 2020 as she was in severe pain.  Susan required repeated doses of opiate pain relief.

On 3 July 2020 Susan continued to experience severe abdominal pain with more opiate pain relief being given for pain under the breast and across the abdomen aggravated by breathing. The recorded plan as of 09.00 on 3 July 2020 was for an urgent CT abdomen and pelvis.  She was brought to the Radiology Department at approximately 16:30 in order to have the urgent scan but due to a difficulty inserting a cannula she was returned to the ward without the scan having been done.

At around 18.00 on 3 July 2020 blood thinning medication, heparin, was administered due to a concern about Susan having a pulmonary embolism (blood clot in her lung).  The recorded plan was for d-dimer, amylase, chest x-ray and a CT scan of her pelvis and abdomen.  A further review at 18.20 took place and she was noted to have a BP of 83/59, oxygen saturation levels of 93%, to be sweating and in pain with severe abdominal tenderness.  The medical records note that the radiology registrar requested surgical review before approving the CT scan.  The Surgical Registrar on call was contacted and it was agreed that an urgent CT scan would take place.  No CT was carried out.

Susan became progressively unwell and at around 00.03 on 4 July 2020 had a cardiac arrest.  She was transferred to the ICU at 02.25 on 4 July 2020. A FAST scan was performed by the ICU consultant which showed free fluid in her abdomen.  A CT scan was requested by the surgical team prior to transfer to the operating theatre which showed splenic enlargement with splenic haemorrhage and blood in the abdominal cavity.

Emergency laparotomy performed on the morning of 4 July 2020 showed a completely disrupted spleen and blood clots in the abdomen.  More than 7l of blood loss was noted.  Susan had a transfusion of approximately 9 units of red blood, 8 units of plasma plus platelets, fibrinogen and factor VII replacement.  Tragically, Susan deteriorated following surgery and was pronounced dead at 12.20 on 4 July 2020.

Limerick Hospital completed an investigation into the circumstances surrounding Susan’s death and found that there was a delay in carrying out a CT scan of the abdomen and pelvis, together with a delay in diagnosing an injury to Susan’s spleen and subsequent internal bleeding.  Had these failings not occurred, in all probability Susan would not have died.

The inquest into Susan’s death took place on the 19 September 2022.  At the commencement of the inquest, lawyers on behalf of Limerick Hospital read out an apology from the Hospital’s Chief Operations Officer which stated ‘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.  Whilst there can be no consolation for the loss of a loved one, 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. I would also like to assure you that valuable lessons have been learned by the Hospital and Staff.’

The Coroner returned a verdict of medical misadventure and endorsed the following recommendations, from the Hospital’s own review of the care:

1. That the Department of Haematology review prescribing and administration of prophylactic and therapeutic heparin for inpatients in consultation with other relevant stakeholders and issue guidance for the UL Hospital Group.
2. That the Hospital ensure that a bed is available at all times in Critical Care.
3. That all departments/units/wards, including the Haematology Department, review their systems in place for clinical handover of inpatient care to ensure that the system is in line with the National Clinical Guideline on Communication (Clinical Handover) in Acute and Children’s Hospital Services (2015).
4. That the Hospital ensures that all Consultants supervising junior doctors have provided written guidance to them on when to contact Consultants in respect of concerns for patients, workload, or any other impact concerning patient safety.
5. That the Hospital ensure that the guidance referred to above in no 4 is provided to all junior doctors during induction training.
6. That the Hospital ensures that Consultants review the workload of all junior doctors so that they are aware of instances of multiple completing and significant demands that cannot be met by the current numbers of staff and that the necessary changes to the tiers of on-call staff being provided outside hours are made.
7. That the Hospital develops written guidance for approving urgent and out-of-hours CT scans for inpatients and on the prioritisation of scans. In addition, that the Radiology Department ensures that relevant clinical information captured on NIMIS and clinical information communicated by phone or person to person communication is reviewed prior to approving and prioritising CT scans.
8. That the provisional schedule for urgent CT scans for inpatients is available to requesting clinicians in line with data protection legislation and kept up to date as urgent investigations are added to the schedule.
9. That the Hospital affirms with the Radiology Department that there is a policy in place that all inpatients who require urgent and out-of-hours CT scans have a suitable intravenous cannula in place before transfer for the scan and that the policy is re-circulated to all relevant departments/units/wards.
10. That the Hospital implements measures required to mitigate the risk of injury to inpatients who require out-of-hours CT scans such as ensuring that transport delays between the location of the patients and the radiology department are not an impediment to patient safety.
11. That the Chief Clinical Director ensures that the UL Hospital Group’s Local Incident Management Procedure is updated to include information on the appointment and role of Chairperson of Review Teams and on the role of Review Officers.

In addition to the above-mentioned recommendations, taken from Limerick Hospital’s own Review, the Coroner also stated that he would be recommending that the HSE and UL Hospital Group consider introducing the increased use of Point of Care ultrasound at a patient’s bedside.

Read more details in the Irish Independent article.  

Please contact Rachael Liston, Managing Partner, on 019123240 or rachael.liston@listonflavin.ie for further information