An inquest has returned a verdict of medical misadventure into the death of an 18-year-old woman who died unexpectedly two days after complications arose during an elective surgical procedure at University hospital Limerick in May of last year.
Jessice Sheedy from Bruff died from multiple organ failure on 11 May, 2018 following complex surgery to remove a large rare, but benign tumour from her abdomen.
An inquest into her death heard that there was a massive haemorrhage in her abdominal area during the surgery, and her blood pressure dropped dramatically.
The surgery was carried out by Dr Ashish Lal who said he could not see clearly where the blood loss was coming from as it was being obstructed by the size of the tumour.
He continued to remove the tumour before the blood loss could be addressed.
It subsequently transpired that an injury had occurred to her aorta, causing a hole in this major blood vessel.
The inquest heard 40 minutes had passed between the time there had been significant blood loss by the patient and a specialist vascular surgeon arriving to help with the surgery.
The patient had lost seven litres of blood during the procedure.
There was evidence from theatre staff that repeated calls were made to Dr Lal to call for assistance. Dr Lal said he did not recall repeatedly refusing help.
But he said in hindsight he would now do things differently with surgery for this type of tumour, his pre-operative preparation would be different and he would involve a second consultant surgeon from the start.
The University of Limerick Hospital Group apologised for the sorrow and distress caused to Jessica' s family over her untimely death. The group said patients and their families had placed their trust in the hospital and the healthcare professionals.
On this occasion they had fallen far short of the standards of care expected the group said.
But they assured the family that valuable lessons had been learned from what happened Jessica.
Coronor John McNamara returned a verdict of medical misadventure.
He said there were missed opportunities in Jessica Sheedy's care and he endorsed 25 recommendations which the hospital had drawn up so that there would not be a repeat of what happened and the same heartache could be avoided for other families.