A verdict of medical misadventure has been returned at the inquest into the death of a 21-year-old man at Mayo University Hospital (MUH).
Adam Mulchrone, from Westport, died from multi-organ failure, caused by meningoccus septicaemia, in early 2019.
The two-day inquest at the Coroner's Court in Swinford heard how he presented at MUH on 26 January that year, with a severe headache and a high temperature.
He was assessed by medics at the hospital’s Emergency Department and subsequently discharged.
In the hours that followed, his condition continued to deteriorate. He was brought back to the ED in the early hours of the following morning.
The inquest, before the Coroner for Mayo, Pat O’Connor, heard that Mr Mulchrone’s vital signs had not been reassessed before he was discharged on the afternoon of 26 January.
Mayo University Hospital has accepted that this should have happened.
In his pathology report, Dr Tamas Nemeth, who carried out a postmortem examination, said there was no evidence of meningitis or encephalitis.
He gave the cause of death as multi-organ failure due to (or as a consequence of) meningoccus septicaemia, with neisseria meningitidis infection an antecedent cause.
Dr Nemeth said that in his 25 years as a pathologist – a period when he had carried out in the region of 4,000 autopsies – he had dealt with only two cases of this type.
Coroner Pat O’Connor described the death as very harrowing, especially for the parents and family of the talented sportsman.
He said he was heartened that the hospital had dealt with the matter in a fair, frank, open and accountable way.
Senior Counsel for the HSE, Conor Halpin read a letter from Catherine Donoghue, General Manager of MUH, expressing condolences for the "immeasurable loss" suffered by the Mulchrone family.
She said the hospital was "truly sorry for the pain and distress caused".
Mr Halpin said the hospital gave an unreserved apology and promised that the "learnings" from what happened would continue to be addressed in the emergency department.
The Mulchrone family solicitor, Ciaran Tansey, said the death was a tragedy of enormous proportions.
He said the family wanted to highlight to the public the symptoms of the disease - vomiting, headache and diarrohea - which took Adam’s life.
