A 76-year-old woman died after a catastrophic complication when her jugular vein was torn during a medical procedure at University Hospital Limerick almost two years ago.
The inquest into the death of Teresa Lyons has returned a verdict of medical misadventure after hearing about the sequence of events leading to her death on 29 December 2016.
She was very seriously ill when admitted to hospital that day suffering from acute renal failure and was transferred to the hospital's ICU early in the evening.
The inquest heard that two attempts were made to insert a central line into her neck, which is used to administer fluids and medication.
While the second attempt was successful, when doctors went to remove the line it snagged as a result of a kink in the line, tearing Ms Lyons' jugular vein with fatal consequences.
She deteriorated rapidly and despite the efforts of doctors to drain fluids and administer CPR for over an hour, Ms Lyons died just after 8.20pm that evening.
A post-mortem found Ms Lyons died from hypovolemic shock as a result of a tear to her right internal jugular vein.
Dr Andras Mikor, who was the consultant anaesthesiologist who was administering the line, and who called for assistance from colleague Dr Catherine Motherway, said injuries to major blood vessels from such procedures were exceptionally rare, and occur in less than 1% of cases, but in this case had a fatal outcome.
The inquest heard that since Ms Lyons' death, the hospital is now using a different type of line for insertion, one that is less likely to kink.
Representatives of the HSE today offered their sincere apologies and condolences to the Lyons family.
Ms Lyons' daughter, Valerie Stewart, said the family was never told their mother was being moved to ICU and were not allowed to see her because the emergency department was so busy that day, and then she died rapidly and alone without any members of her family present.
She said they sought the inquest because the treatment the family had got from the HSE was absolutely disgraceful and that they had been stonewalled for almost two years.
At least today they got some answers, she said, and some closure, and hopefully it will never happen to another family.
Ms Stewart said the family was also upset by the language on a computerised form they got from hospital administrators which read that "surgery was performed on the wrong body part" and this had been used as part of an explanation on a drop-down menu.
Coroner John McNamara said it was clear the Lyons family had suffered greatly as a result of their mother’s death.
He noted the wire used for the procedure was now changed to one which was less likely to kink, and the use of the computerised form which had caused the family such upset had been discontinued.
However, he said the communication between the HSE and the family could have been better and could have helped the family with their grief and upset.
