A verdict of medical misadventure has been returned at an inquest into the death of a 60-year-old woman who died in St James's Hospital, Dublin, after having her thyroid removed.
The court heard evidence that the registrar on call initially did not come into the hospital when concerns were raised about neck swelling and the patient's difficulty breathing.
Marian Tracy, from Lucan, died four days after having a thyroidectomy in May 2015.
The cause of death was lack of oxygen to the brain, secondary to breathing difficulties caused by post-operative clotting.
As a private patient she went into St James' Hospital to have a thyroidectomy as her surgeon said because of an underlying medical condition the teaching hospital would be "better staffed if a problem arose."
The surgery was described as "uneventful" but Ms Tracy was kept in hospital over the weekend for observation.
The following evening she developing swelling in her neck and had difficulty breathing.
Nurses on duty that night and an intern doctor gave evidence that they were concerned she had a haematoma.
The ear, nose and throat registrar on call, Dr Monica Istovan, was not on site.
She was contacted on four occasions over the evening by nurses and the intern but did not come into the hospital.
She requested photographs of the ill patient and then came in, by which time Ms Tracy had gone into respiratory arrest.
The intern, who was 11 months qualified, was responsible for six wards with 20-25 people in each that night, and was the most senior clinician on site to deal with Ms Tracy's difficulties.
The ENT registrar on call, Dr Monica Istovan did not give any evidence to the coroner's court, although attempts were made to contact her.
After the verdict of medical misadventure was recorded by the coroner, St James' Hospital apologised "sincerely" to the family of Ms Tracy and said it "deeply regrets the failures that led to Marian Tracy's death" while she was in the hospital's care.
The coroner made a number of recommendations, including that the hospital and HSE consider having an onsite on call doctor, in the interest of patient safety.
Speaking after an inquest returned a verdict of medical misadventure, Marian Tracy's husband William said her death could have been avoided. pic.twitter.com/waFgXwDXbW
— RTÉ News (@rtenews) July 12, 2017
Speaking afterward, William Tracy said his wife's death has "left a huge void" in his family's lives.
The family hopes that her death would not be in vain and that the coroner’s recommendations will be put on place so another family would not have to suffer.
