An inquest has heard how a patient who died at University Hospital Limerick had fallen from a trolley in the busy emergency department and may have been dead for over an hour before staff found him on the floor.
A verdict of death by medical misadventure was recorded into the death of Martin Abbott from Shannon, Co Clare, who died in December of 2019.
University Hospital Limerick previously acknowledged "deficits in his care" and offered apologies to the Abbott family at Limerick Coroner's Court in Kilmallock.
Mr Abbott, 65, was described as a much-loved father, husband and taxi driver from Deilginish in Shannon.
The court heard he had a complex medical history, including a past kidney transplant, but was working and had enjoyed a family holiday in Poland in the weeks prior to becoming unwell.
In her deposition to the court, Mr Abbott's only daughter Anne Marie explained he had presented to the Emergency Department at UHL on Saturday 14 December 2019 after a week of feeling unwell with fever, cough and diarrhoea.
He was given antibiotics for a diagnosis of legionnaire’s disease as well as IV fluids while awaiting admission to a hospital bed, and was placed on a trolley in an isolation cubicle due to his immunocompromised state.
On his third day on the trolley, Ms Abbott asked nurses to get a doctor to see her father as she left him at 10pm. She said she "was concerned he was not being looked after correctly" and his breathing was laboured.
She said she could not get through to the ED by phone that night, but at 6am the following morning was rung by her mother Mary to say gardaí from Shannon were at the door informing her they needed to contact the hospital immediately.
On arrival at 6.30am hospital staff told them that Mr Abbott had died following "a turn" overnight and had been found lying on the floor by his trolley at 4.40am. She said they were initially told he had suffered a cardiac arrest, then a broken neck and no cardiac incident, but were later informed a pathologist had made a mistake as he had not broken his neck.
She said she and her mother were shocked as her dad "should have been home for Christmas" after being admitted for a treatable illness and were upset at the manner in which they were treated by staff at UHL.
Medical evidence from nurses and doctors at UHL confirmed that Mr Abbott was last seen by a doctor at 7.32pm and that was the last time he was seen by a doctor before he was discovered unresponsive on the floor at 4.40am.
While nurses had recorded treatment for his heightened fever and lowering oxygen levels, recommended monitoring frequency of at least hourly checks based on his oxygen levels were not observed and his vital signs were last checked at 3am when it was noted he had been taking his oxygen mask off.
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At 4.40am staff recounted being called to a cardiac arrest in Mr Abbott’s ED cubicle. He had been found lying face down on the floor by his trolley. Multiple rounds of CPR were carried out, but ventilation was not possible as doctors noticed "rigor mortis causing stiffness in his face and neck" and he was pronounced dead at the official time of 4.55am.
In his evidence, Consultant Pathologist Dr Gabor Laskai said Mr Abbott died from cardiorespiratory failure due to lobar pneumonia, noting coronary arterial sclerosis and hypoxia as contributory factors.
He clarified a neck injury found on Mr Abbott was a ligament tear and not broken vertebrae, which had likely been caused as he fell from his trolley but was not a contributory factor in his death.
Coroner John McNamara recorded a verdict of death my medical misadventure, but said this was not to blame anybody as that was not the role of the coroner’s court.
He said medical evidence showed that Mr Abbott should have been reviewed more frequently and had his case escalated, but added that overcrowding at Limerick’s ED put pressure on everyone.
Based on the pathologist’s evidence regarding rigor mortis, he said it was likely that Mr Abbott had been lying on the floor for approximately one hour.
Offering condolences to the Abbott family, he endorsed recommendations to improve patient safety at UHL but observed that overcrowding is a difficult problem to solve there.
Legal counsel for UHL said the hospital is taking steps to resolve these issues and repeated apologies for deficits in care to Mr Abbott’s widow and daughter who had questioned "how many more people have to die before the system changes"?
