The mother of an 18-year-old woman, who died after an operation at University Hospital Limerick (UHL) in 2018, says her family feels utterly let down, not only by the surgeon who has admitted professional misconduct in her care, but also by the healthcare system that allowed him to practise.
Jessica Sheedy, from Bruff in Co Limerick, was admitted to UHL on 8 May 2018 to have a large and rare but benign tumour removed from her abdomen.
She died three days later, on 11 May, in the hospital's High Dependency Unit, after suffering multiple-organ failure from complications which arose during the surgery.
During the procedure Ms Sheedy had sustained a "massive haemorrhage" in her abdominal area caused by an injury to her aorta.
The committee at a fitness-to-practise inquiry of the Medical Council found that three allegations of professional misconduct and ten of poor professional performance, made against her surgeon, Dr Ashish Lal, have been proven beyond a reasonable doubt.
Dr Lal had made full admissions in relation to these allegations.
The proven allegations of professional misconduct included that Dr Lal did not seek assistance from a vascular surgeon "in a sufficiently timely manner" when Ms Sheedy suffered significant blood loss during the proceedure, despite being prompted to do so by staff who were in surgery with him on more than one occasion.
Among the incidents of poor professional performance admitted to by Dr Lal was his decision to proceed with the operation where he did not have the appropriate experience, and to carry it out with inadequate surgical support or expertise.
The surgeon also admitted that he had underestimated the complexity of the surgery, had failed to plan adequately for the potential risks or adverse outcomes and had failed to properly brief and adequately prepare the team in surgery.
Inquiry chairperson, Marie Culliton, said that the committee considered each of the 13 proven allegations to be "a serious failing by Dr Lal".
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'The light of our lives'
Speaking outside the Medical Council of Ireland, Jessica Sheedy's mother Ann said Mr Lal had admitted poor professional performance and professional misconduct "at the 11th hour", noting it was six years after the family made their complaint to the Medical Council and almost eight years after their daughter's death.
Ms Sheedy said Jessica's family were "at a complete loss as to why the Medical Council Fitness to Practise hearing has "been so delayed" and described it as "an extremely harrowing journey".
"We had to endure many obstacles in our fight for justice for Jess," Ms Sheedy said, "we persevered because we do not want another young life to be unnecessarily taken".
"We are heartbroken, bereft and extremely angry that this happened to us in one of the wealthiest countries in the world with one of the most expensive and ineffective healthcare systems," Ms Sheedy said.
"We feel utterly let down not only by the arrogance of an incompetent surgeon but by a healthcare system that allowed this man to practise and, as far as we are concerned, experiment on our daughter and even video the surgery without her knowledge or consent."
"Jessica was the light of our lives, that light went out on the 11th of May 2018 and we will never be the same, our lives and the lives of our family and friends and all who knew and loved Jess have been changed forever," Ms Sheedy said.
'No doubt we failed Jessica' - HSE
HSE Mid West has offered an "unequivocal apology" to Jessica's family for "their unimaginable and devastating loss".
"We accept full institutional responsibility for the catastrophic and irreparable harm caused," a statement read,
It said: "Jessica lost her life because of a series of significant and avoidable clinical errors in the lead up to and during her surgery.
"Specifically, our investigations have concluded that adequate safeguards were not in place to prevent this high-risk operation, a procedure that should not have been performed at our facility at that time."
However, it said it wanted to "reassure" the community that "this was not a reflection" of its wider surgical and medical departments.
"It is with a profound sense of remorse and regret that Jessica lost her life owing to our failures," said Sandra Broderick, Regional Executive Officer, HSE Mid West.
"There is no doubt that we failed Jessica and her family. The failure was one of significant proportions, with clear catastrophic consequences," Ms Broderick added.
Legal submissions on sanctions
The Fitness to Practise Inquiry will resume tomorrow when it will hear legal submissions on potential sanctions against Dr Lal.
Yesterday Simon Mills SC, told the inquiry that Dr Lal had wished to offer an unqualified apology at the hearing for the shortcomings in his care.
However, Mr Mills acknowledged that Ms Sheedy's family had indicated they did not want to hear an apology and that he and his client would respect those wishes.
Nevertheless, Mr Mills asked that this would be noted by the Committee in consideration of any sanction that might be imposed on Dr Lal.
At the inquest into Jessica Sheedy's death in November 2019, a statement of apology was read out on behalf of the then University of Limerick Hospitals Group's acting chief executive Noreen Spillane, in which she "apologised sincerely and unreservedly for the sorrow and distress caused to Jessica's family over her untimely death and for the personal trauma experienced by them."
UL Hospitals Group told the inquest that it had drawn up 25 recommendations aimed at learning lessons and to prevent similar tragedies from happening.
