An inquest into the care of a 76-year-old man who died from sepsis, days after being discharged from University Hospital Limerick, has returned a verdict of medical misadventure.
Staff at UHL and the HSE have apologised unreservedly to the family of Michael Cuddihy and admitted failings in his care.
"We apologise for the failings in the care that sadly and unfortunately led to Michael's untimely death. We apologise unreservedly for your loss and the distress and upset that this has caused," UHL and the HSE said in a statement.
The hospital said there was a commitment to implementing all of the recommendations in an ongoing review.
His family said he was "treated appallingly and allowed to die when he had so much to live for".
In November 2023, Mr Cuddihy was taken by ambulance to UHL after experiencing vomiting and severe pain.
He was told that he had a stomach bug and was free to go home but asked to stay overnight at the hospital as he was not feeling well.
The following day he was discharged and two days later he died from sepsis as a result of a trapped gallstone.
His post-mortem results would later conclude he had died after an infection which went untreated and led to sepsis.
Hospital notes seen by RTÉ Investigates showed that after Mr Cuddihy asked not to be discharged, he was moved to another section of the Emergency Department and overnight he was found vomiting by nursing staff.
The notes also showed that he had a raised temperature and blood pressure but it appears there was no medical follow-up.
Michael Cuddihy remained on a trolley for 18 hours.
A number of medical witnesses were called to give evidence including the doctor who had examined Mr Cuddihy.
Dr David Herlihy said he reviewed the patient multiple times during his shift.
He said Mr Cuddihy did not trigger any sepsis markers such as fever, vomiting and worsening pain during his shift and noted that he should be monitored for any changes before finishing his shift at 10pm.
However, Mr Cuddihy's condition deteriorated overnight and he displayed the "red flag" symptoms including a spike in temperature, blood pressure and vomiting.
Blood tests had been done earlier which would routinely look for infection but they were incomplete.
Dr Herlihy said he did not realise that liver function tests had haemolysed and had he known he would have had them redone.
Under cross-examination, the doctor said the emergency department was very busy on the day in question with trolleys in the corridor at "surge capacity".
Emergency Department Consultant Dr Alan Watts said a protocol is now in place for the receiving and interpreting of bloods results.
Furthermore, an Emergency Medicine Early Warning system has been implemented to recognise and respond to deteriorating patients.
The inquest heard how handover notes showed Mr Cuddihy's temperature was stable, no longer in pain and seen as fit to be discharged based on his vitals.
A framed photograph of Mr Cuddihy was placed by his family on the bench at the inquest.
In her deposition, Áine Cuddihy recounted the day before her husband's death at home.
"On Wednesday he was much the same. He slept for longer and really only woke up to take a drink, which he then vomited. Again I asked him if he’d like to go back into the hospital and he’d say 'they told me it was a bug and it will get better.’
"Neither he nor I were medically qualified and it did not enter our heads that they were wrong.
"I stayed up all night on Wednesday night and would look in at Michael to check he was ok. I didn’t wake him up if I could hear him sleeping.
"Eventually at 9.30 that morning I lay on my bed and dozed off asleep.
"Just before 12 noon I went out to his room again and his legs were out from under the duvet. I put my hands on his feet and said "Michael, your feet are freezing, I’ll put them in under the quilt".
"There was no response from him and then I moved his arm. It was cold and hard. I then realised he was dead. I immediately called for an ambulance. I was distraught.
"The ambulance crew came and were extremely kind but told me there was nothing they could do. Shortly after that two members of the Garda Síochána arrived.
"They told me my options regarding getting a post-mortem and I decided this was what I wanted. They then alerted the undertaker who collected Michael and brought him back to UHL for the PM (post-mortem).
"My wonderful husband of almost 48 years was taken from my life and the lives of his children, their partners and his grandchildren.
"He was kindness personified and would never have neglected anyone or caused harm. I feel he was treated appallingly and allowed to die when he had so much for which to live," she said.
In a statement, the staff at UHL and the HSE apologised unreservedly and endeavoured to implement recommendations in an ongoing review.
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'Our dad should not be gone'
Speaking outside following the verdict, the family thanked the coroner and said they welcomed the verdict.
Mr Cuddihy's daughter Anne said the verdict "goes some way to acknowledging the fact that our dad should not be gone".
"He should still be here with us, fighting fit and playing with his grandchildren as he was until a few days before his death," she said.
However, she added: "We do feel like there needs to be a lot of work done in terms of alleviating the issues in the hospital in regards to overcrowding."
Anne described her father as wonderful and kind, adding that he was "special".
"He absolutely adored his family and his soulmate, my mother and he was besotted with his four grandchildren."
She said his death "could of been avoided if things had been done correctly".
His wife Áine Cuddihy said Michael "was and is my best friend" and her soulmate.
She described him as a wonderful husband, father and grandfather.
Ms Cuddihy said she "misses him so much".
