HSE apologises over delay in acting on X-ray showing man aged 91 had swallowed dentures
At the High Court sitting in Cork, Ms Justice Carmel Stewart approved a €55,000 award on Wednesday to the family of Daniel O'Leary, late of Knockbrack in Banteer, Co Cork.
The court heard how on July 26th, 2022, Mr O'Leary, a resident at Kanturk Community Hospital, Co Cork, started coughing while sitting in a chair.
He was uncomfortable and complained about something stuck in his throat.
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He was holding his hands to his throat and his partial bottom denture of two teeth was missing.
Staff went to his aid and he was transferred to University Hospital Limerick. Paramedics told doctors he had possibly inhaled a denture consisting of two lower teeth.
He was examined in the emergency department, and X-rays showed no evidence of the dentures or any foreign body. Mr O'Leary was admitted to hospital.
He was further assessed the following day and again a doctor found no evidence that his upper airway was obstructed.
A diagnosis of respiratory sepsis was made on a background of likely aspiration due to impaired swallow. Mr O'Leary was given fluids and antibiotics intravenously. He also received oxygen therapy.
He was assessed two days later when he appeared to be improving. He remained in hospital over the bank holiday weekend, with his care being taken over by a consultant physician and geriatrician on August 2nd.
Ms Justice Stewart was told a chest X-ray carried out on his arrival at the hospital on July 26th was only reported on July 30th. It showed 'densities in the upper neck, likely reflecting a foreign body'.
The court was told there was no evidence the X-ray report had been seen or acted on by medics in the hospital until the consultant geriatrician came on duty on August 2nd.
A CT scan carried out on August 3rd did not detect any foreign body in Mr O'Leary's neck or chest. However, later that day nursing staff carried out a suctioning procedure on the patient and detected dentures in the lowest part of his throat.
The ENT team removed the dentures on August 4th, 2022, nine days after he was taken to hospital.
Mr O'Leary continued to deteriorate physically and his care became palliative. He was brought back to Kanturk Community Hospital where he died peacefully on August 12th, 2022.
Eamon Shanahan, for his family, said they received an apology from the HSE.
In the apology the health service acknowledged the delay in the review of the relevant X-ray and said it has 'learned from the incident' and implemented a recommendation identified by the coroner at the inquest concerning Mr O'Leary's death.
'We wish to apologise for the failings in the care provided and for the distress and upset that this has caused,' it said.
In effect there was a week between the X-ray, which showed a potential blockage, and when it was acted upon.
Ms Justice Stewart extended her condolences to Mr O'Leary's family.
'Your father had a long and fruitful life,' she said. 'There is never a good time to lose a loved one, or to endure the trauma he endured. It doesn't bear thinking about. Hopefully you can put this behind you and reflect on the good times.'
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