The family of a woman, who believe her death two weeks after suffering a fall was avoidable, have issued legal proceedings against Tallaght University Hospital over its treatment of her injuries.
Relatives of Martha "Josie" Gibbons, of Fair Green, Caherciveen, Co Kerry have welcomed a verdict of death by misadventure recorded at her inquest at Dublin Coroner's Court this week.
The family’s solicitor, Scarlett O’Sullivan, said Ms Gibbon’s children were "anxious to ensure that no other family would suffer a similar, unnecessary death".
The deceased’s daughter, Victoria Gibbons, told the inquest that she and her mother had been attending a wedding at Tulfarris Hotel in Blessington, Co Wicklow on 26 October, 2018 when she stumbled and grabbed her mother which resulted in both women falling down stairs.
It was discovered at Tallaght University Hospital that the deceased had suffered a broken arm and fracture to her pelvis as a result of the incident.
Ms Gibbons said her mother was discharged on 31 October, 2018 with a referral to a clinic at University Hospital Kerry in Tralee.
However, Ms Gibbons said her mother stopped breathing as they were leaving the hospital and she was brought back to the emergency department before being transferred to an intensive care unit.
She died nine days later on 9 November, 2018 on her 76th birthday.
A post mortem concluded Ms Gibbons, a mother of three who came originally from England, died as a result of a cardiac arrest due to a pulmonary embolism which was most likely caused by a blood clot.
Ms Gibbons said her mother had been in good health before her fall and had been working regularly in a local shop in Caherciveen.
She expressed concern that she had never seen her mother wearing compression stockings to lower the risk of blood clots during her stay in hospital.
An orthopaedic consultant who treated Ms Gibbons, Derek Cawley, said he had been concerned that the patient could be suffering internal bleeding as a result of her broken arm as well as a head injury suffered in the fall.
Mr Cawley admitted he had taken an active decision not to give any medicine to Ms Gibbons to reduce the risk of blood clots as she was not fully immobilised.
However, he told the coroner, Cróna Gallagher, that he did not think that giving her blood thinners would have prevented her death.
The consultant acknowledged he had made "a judgement call" in trying to balance the need between preventing internal bleeding and blood clots in the patient.
He pointed out that nobody had disagreed with his treatment of Ms Gibbons after her case had been reviewed by a multi-disciplinary team.
Mr Cawley, who said he had examined Ms Gibbons at least once every day, said he did not know why she was not wearing compression stockings as he believed patients like her were given them unless there was a particular reason not to.
He assessed Ms Gibbons as a low to moderate risk of developing blood clots.
However, Mr Cawley admitted that no CT scan had been carried out on her before she was discharged from the hospital.
He described her readmission shortly after her discharge as "most unexpected".
Under cross-examination by Doireann O'Mahony BL for the Gibbons family, the consultant accepted there was an ambiguity about the "optimal safe thing to do" in such cases.
However, he said there was no evidence that Ms Gibbons was unfit to be discharged from hospital.
Mr Cawley noted she had originally required a walking frame for mobility but her condition had improved and she was on the point of using crutches by the time she left hospital.
Following her verdict of death by misadventure, Dr Gallagher endorsed the findings of a report commissioned by Tallaght University Hospital following Ms Gibbon’s death which contained a series of recommendations.
Mr Cawley said he understood there had been "significant clarity" in relation to documentation and protocols about the care of such patients.
In a statement, the Gibbons family said their mother had died "due to the mismanagement of her care".
They added: "It should never have happened but it did - as a family we are heartbroken."
