Tallaght Hospital has invited the family of a man who died of a rare, major artery condition which was not diagnosed until a day after he was admitted to the hospital, to meet with staff to see how they can learn from his death.
The family of Timothy Fleming say they hope that the inquest into his death will set a precedent where hospitals and families can work together to set better standards and avoid unnecessary loss of life.
Dublin District Coroner's Court heard that Mr Fleming, 69, had been visiting Dublin from London in February 2015 when he was admitted to Tallaght Hospital with extreme pain in his abdomen.
He was attended to by doctors who originally suspected gastritis or an ulcer.
A tear to the aorta was also considered but no definitive diagnosis was made.
Mr Fleming was administered morphine for pain relief. He was discharged at 2am on 6 February 2015, and returned to the hospital two hours later, still in pain.
An inquest into his death was told that doctors who were on-call at Tallaght Hospital consulted with a registrar, who was not at the hospital, throughout the night over the phone.
A CT scan was ordered when the registrar returned to the hospital at 6am, and it confirmed that the patient had suffered an aortic dissection - a tear in the wall of the major artery carrying blood out of the heart.
Mr Fleming was transferred to St James's Hospital to be operated on by a consultant vascular surgeon later that morning.
He died in the operating theatre a short time after the procedure began.
A jury at an inquest into his death recorded a verdict of medical misadventure, and recommended that Tallaght Hospital have surgical and medical staff on site 24 hours a day to make decisions on patient care.
It recommended that all medical staff be made aware of symptoms of aortic dissection.
It also recommended that all differential diagnoses be recorded in patients' charts for dissemination of information for continuity of care.
Solicitor Kevin Power, on behalf of Tallaght Hospital, said the hospital wanted to express its sincere regret regarding aspects of Mr Fleming's care, and wished to invite his family to meet with them to see how best the hospital can learn from the issues raised at the inquest.
Solicitor for the family Roger Murray said they were willing to cooperate to apply their experience with hospital staff.
Speaking outside the Coroner's Court, Caroline Fleming, daughter of Mr Fleming, said, the family is satisfied with the verdict of death by medical misadventure, and are pleased that the hospital "accepts that there are many aspects of their patient care that need urgent review".
She said: "The hospital has taken the unprecedented steps of inviting our family to work with them on policy and guideline changes, and we hope these changes will bring about the prevention of further unnecessary deaths in this country, regardless of their condition."
