A young mother bled to death following a "systems failure" in her care while she was an inpatient at University Hospital Limerick, a barrister for the woman's family told her inquest today.
The UL Hospitals Group issued an unreserved apology to the family of Susan Doherty, 47, who died in UHL on 4 July 2020, eight days after she presented there with a low white blood cell count, sore throat and high temperature.
Doctors requested an "urgent" scan of Ms Doherty’s abdomen and pelvis after she complained of severe pain in her chest, but this was not followed up on and she died after suffering a massive bleed to her spleen.
Ms Doherty presented at UHL with a medcial history of rheumatoid arthritis and autoimmune neutropenia - a blood disorder where the immune system attacks white blood cells that fight infection.
She had been routinely receiving the therapeutic GCSF, which carries a "very rare" risk of splenic rupture, the inquest heard.
After being admitted to a ward she received blood thinning therapy which may have exacerbated the bleed on her spleen.
By the time she received the "urgent" CT scan nearly 24 hours later she had suffered a cardiac arrest.
Ms Doherty died around midday on 4 July shortly after eventually undergoing surgery to remove her ruptured spleen.
Conor Halpin, Senior Counsel, acting on behalf of the UL Hospitals Group, expressed his "deepest sympathies to Susan's family" and read out a letter of unreversed apology which was signed by Noreen Spillane, chief operations officer, UL Hospitals Group.
"Patients and their families put their trust in hospitals and in healthcare professionals and on this occasion we have fallen far short of the standards of care expected," Ms Spillane wrote.
"I wish to apologise sincerely and unreservedly for the sorrow and distress caused to you and your family over Susan’s untimely death and for the personal trauma experienced by you and your family."
Ms Spillane concluded: "Valuable lessons have been learnt by the hospital and its staff".
Eleven recommendations were made following an internal review by the hospital group but these have yet to be implemented.
Mary McKiernan, a senior nurse manager, who has since retired, agreed under cross examination that Ms Doherty was not monitored as per the hospital’s protocols and that the patient’s ward was "short staffed".
Ms McKiernan said she "pushed" for Ms Doherty to receive an urgent CCT scan after she became concerned for her.
There was delay in weekend rostered on-call consultants being made aware of Ms Doherty’s condition, it was also heard.
Ms McKieran said she was not aware of any system at UHL that confirmed urgent scans were followed up on.
Ms Doherty's condition further deteriorated and it was determined she required a bed in the High Dependency Unit (HDU) for seriously ill patients, but none were immediately available.
Ms Doherty suffered a cardiac arrest at five minutes past midnight on 4 July, she was transferred to the Intensive Care Unit after doctors successfully resuscitated her.
Scans were not carried out until around 5am and the CT scan confirmed a major hemorrhage in Ms Doherty’s spleen.
She underwent emergency surgery to remove the ruptured spleen, but was pronounced dead around midday on 4 July.
Coroner John McNamara said it appeared "a conflict" between clinicians working on the frontline of the hospital and "capacity and access issues" were "at the heart" of Ms Doherty’s "tragic" death.
He said if a CT scan had been performed on her earlier, "it would have without any shadow of a doubt changed the trajectory of Susan’s treatment and eradicated doctors concerns about (a lung blood clot)".
It appeared that "without a CT scan" doctors were "fighting with one hand tied behind their backs", he said.
An autopsy on Ms Doherty’s body concluded that cause of death was due to "shock intra abdominal hemorrhage, due to splenic rupture".
Coroner John McNamara recorded a verdict of "medical misadventure", but said there was no evidence of any wrongdoing by anyone involved in Ms Doherty’s care.
Intensive Care Consultant, UHL, Dr Catherine Nix, told the inquest that doctors in America were using handheld "bedside" scans to fast-track diagnosis in their patients and that this technology should be used more often in UHL and other Irish hospitals.
Mr McNamara recommended the HSE and the UL Hospitals Group consider "increased use" of these scan devices.
Ms Doherty’s husband, Roland Doherty, represented by Sara Antonioni BL instructed by Rachael Liston, Liston Flavin solicitors, Cork, said: "It’s not going to bring Susan back, but the HSE accepted there were major failings.
"They need to change their systems to ensure this this doesn't happen again, I don't want anyone else to go through what I have been through for the last two years."
Paying tribute to his late wife, he said: "She always had a smile on her face no matter what, and she adored the ground our beautiful daughter Charlotte Rose (now aged five) walked on, but she only had two years with her."