A patient in Wexford General Hospital suffered fatal internal bleeding after medical staff missed several opportunities to intervene to address her deteriorating condition, an inquest has heard.
A verdict of medical misadventure was returned into the death of Marie Lynch of St Aidan's Village, Enniscorthy, Co Wexford, after Coroner for Wexford Dr Seán Nixon said there had been delays in treatment being provided to the patient during her stay in hospital.
She died in hospital on 24 March 2021.
The inquest also heard that the patient had suffered internal blood loss as a result of anti-blood clotting medicine that she had been given longer than necessary.
Dr Nixon was told by Solicitor Ambrose Cuddy that Ms Lynch had been a very active grandmother who was more like a sister to her children and grandchildren prior to her admission to hospital.
Mr Cuddy said that she had been admitted to hospital for treatment on 11 March 2021 with a painful leg following a fall and had been diagnosed with cellulitis.
Mr Cuddy also said that a CT scan to check for clots on the lung was ordered on 19 March 2021 but it was not carried out until three days later.
He told the inquest that it seemed that it was bad to be in hospital over a weekend as "nothing happens".
Mr Cuddy said the CT scan taken on 22 March 2021 showed there was no clot on the patient's lung but her treatment with the anticoagulant was not stopped for a further 24 hours though her condition was deteriorating.
By the following day, according to Mr Cuddy, Ms Lynch was vomiting blood and also passing blood in her stool as well as suffering nosebleeds.
Mr Cuddy said extensive bleeding in the patient could have been addressed by a blood transfusion.
The inquest heard she died in the early hours of 24 March 2021, after suffering a cardiac arrest.
"Ms Lynch's family were tormented and frightened and have a total loss of confidence in Wexford General Hospital," said Mr Cuddy.
A post-mortem showed Ms Lynch had died as a result of hypovolemic shock due to blood loss at multiple sites within her body.
The inquest also heard that the patient suffered internal bleeding of up to 1.3 litres of blood while an additional unmeasured quantity of blood was also found in her pelvic area.
Pathologist at Waterford University Hospital Mutax Nur said that Ms Lynch had suffered significant internal bleeding.
The pathologist said it was not possible to say when the blood loss had started but he accepted there had been a significant loss of blood over a short period of time.
Consultant at Wexford General Hospital Professor Colm Quigley said it was standard practice to give an anticoagulant to a patient who was at risk of deep vein thrombosis like Ms Lynch.
Prof Quigley admitted that he was unhappy that a CT scan ordered for Ms Lynch on 19 March 2021 was not carried out for a further three days.
Prof Quigley accepted there could have been an earlier intervention from 23 March 2021 to address the patient's deteriorating condition.
He believed there was a window of about three hours up to 9pm that day when Ms Lynch's condition could have been stabilised with a blood transfusion.
Since the patient's death, Prof Quigley said improvements had been made in the training of staff at Wexford General Hospital about recognising patients with a deteriorating condition.
However, Prof Quigley said the failure to recognise a deterioration in patients and to provide a rapid response in hospitals was "a national issue".
Returning a verdict of medical misadventure, Dr Seán Nixon said there was evidence "of a lot of missed opportunities" and a failure to escalate treatment for her deteriorating conditions.
The coroner also said there had been a significant deal in carrying out a CT scan on Ms Lynch and in addressing her internal bleeding, particularly in the final 24 hours of her life.
Dr Nixon said there had been an issue with maintaining correct and adequate medical notes about the patient's care.
