Latest news with #medicalerror
BreakingNews.ie
6 days ago
- Health
- BreakingNews.ie
Man (91) died after week-long delay in detecting swallowed dentures
The HSE has issued an apology to the family of a 91-year-old man who died with choking complications after a hospital took a week to act on an x-ray which revealed that he had swallowed dentures. At a sitting of the High Court in Cork on Wednesday, Ms Justice Carmel Stewart also approved an award of €55,000 to the family of Daniel O'Leary, late of Knockbrack, Banteer in Co Cork. Advertisement Mr O'Leary was a resident at Kanturk Community Hospital in Co Cork. The High Court heard that at 11:25am on July 26th, 2022, Mr O'Leary started coughing whilst sitting in a chair. The pensioner also complained of something being stuck in his throat. Mr O'Leary was uncomfortable and holding his hands to his throat. His partial bottom denture of two teeth was missing. Staff rushed to his assistance and Mr O'Leary was transferred by ambulance to University Hospital Limerick. Paramedics informed doctors that the elderly man had possibly inhaled a denture consisting of two lower teeth. He was examined in the A&E department and a number of x rays carried out showed no evidence of the dentures or any foreign body. Mr O'Leary was admitted to hospital. Advertisement 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 was subsequently assessed on July 29th, 2022, and 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, 2022. Ms Justice Carmel Stewart was told that a chest x ray carried out on his arrival at hospital on July 26th was only reported on July 30th. It showed 'multiple linear densities in the upper neck, likely reflecting a foreign body'. Advertisement The High Court was told that there was no evidence that the report on that x ray had been seen or acted on by medics in the hospital until the consultant geriatrician came on duty on August 2nd, 2022. A CT scan carried out on August 3rd, did not detect any foreign body in Mr O'Leary's neck or thorax. However, later that day nursing staff carried out a suctioning procedure on the patient detected dentures in his left hypo-pharynx —in the lowest part of his throat. The ENT team removed the dentures on August 4th, 2022, nine days after the pensioner was taken to hospital. Mr O'Leary continued to deteriorate physically and his care became palliative in nature. He was brought back to Kanturk Community Hospital where he passed away peacefully on August 12th, 2022. Advertisement Eamon Shanahan, solicitor, representing the family of the deceased said that they had received an apology from the HSE. In the apology they acknowledged the delay in the review of the relevant x ray. 'The hospital has learned from the incident and has implemented the recommendation identified by the coroner at the inquest. We wish to apologise for the failings in the care provided and for the distress and upset that this has caused.' 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 the family of the deceased. Advertisement Ireland Former TD Colm Keaveney banned from driving for fo... Read More "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.' Mr O'Leary was predeceased by his wife Nan. He is survived by his adult children John, Margaret, Donal and Deirdre, his eight grandchildren, and two great grand children. The O'Leary family expressed their appreciation for the care given to their father in his final years at Kanturk Community Hospital.
RNZ News
21-07-2025
- Health
- RNZ News
Man sent home without doctors checking for potentially fatal condition
The junior surgical registrar who assessed the man who came to hospital with signs of internal bleeding was not aware they needed to investigate the possibility of an aorto-enteric fistula, the commissioner said. Photo: 123RF A man was sent home from hospital without doctors checking for a potentially fatal condition due to a communication breakdown, the Health and Disability Commissioner has found. The man died the following day of unrelated causes. The man, aged in his 60s, had undergone major surgery on his abdominal aorta - the main artery from the heart - two years before going to hospital in Health NZ's Southern region in 2019 with signs of internal bleeding. In findings released on Monday, the commissioner said the junior surgical registrar who assessed him was not aware they needed to investigate the possibility of an aorto-enteric fistula (AEF) - a serious and sometimes fatal complication after that type of surgery. Commissioner Morag McDowell said the doctor did not consult a senior vascular surgeon for advice. Later, the doctor told other medics there was "no evidence of aortic pathology", which a gastroenterologist mistakenly took to mean the condition had been ruled out. The gastroenterologist did not verify that against the man's medical records before discharging him, the commissioner said. The man died at home the following day. His son complained his father was discharged when still unwell with unidentified internal bleeding. While the cause of death was unrelated to an AEF, the commissioner said Health NZ Southern had failed to provide services with reasonable care and skill. "Given that an AEF is a life-threatening diagnosis that needs to be investigated urgently, there was a concerning lack of responsibility taken by anyone to ensure that this had been done," she said. "Staff failed to communicate effectively, deferred to others, and passed on the responsibility without using critical thinking or making individual assessments." McDowell said she accepted the junior surgical registrar would not have known about the possibility of an AEF. But it was concerning he documented "no evidence of aortic pathology" - mistakenly leading others to false conclusions - without seeking advice from a vascular surgeon, she said. Overall, McDowell found the doctor was not in breach of the Code of Health and Disability Services Consumers' Rights, but had reflected on these events and made changes to the way he documented in clinical notes. Hearing about the case had affected the junior surgical registrar deeply, McDowell said. "He has spent considerable time reflecting on the events. He believes that he practises very differently now," she said. The gastroenterologist "should have confirmed, by review of the clinical record, that the appropriate investigations had been completed", McDowell said. "I am critical of his lack of critical thinking and diligence." He had also "reflected on how he accepts information from other providers", she said. "I consider this to be appropriate and to serve to minimise the risk of such an event happening in the future." Health NZ Southern had updated its registrar orientation programme following the man's death to ensure on-call surgical registrars discussed any subspecialty questions with an appropriate specialist, McDowell said. In her recommendations, she advised sharing the findings with staff as a "learning resource to highlight the importance of critical thinking at each stage of care". She also recommended providing ongoing refresher training on AEF and outlining the expected process for identifying and ruling it out. Sign up for Ngā Pitopito Kōrero , a daily newsletter curated by our editors and delivered straight to your inbox every weekday.
BBC News
15-07-2025
- Health
- BBC News
Norfolk hospital 'failed to monitor' overdose patient
Hospital staff failed to properly monitor a woman who died from cardiac arrest following an overdose, a coroner has at the James Paget Hospital in Gorleston, Norfolk, also did not realise Susan Young had unused medication in her belongings when she died in August Yvonne Blake said instructions to make sure the 63-year-old was attached to cardiac monitoring were not passed on when she was moved from an emergency to the hospital she said she wanted to know what action it would take to prevent similar deaths in the future. The hospital has been approached for comment. An inquest heard Miss Young had previously suffered various cardiac problems, including a heart took an overdose of prescription medicine for her epilepsy on 22 August, then another the following day – after which she was taken to Ms Blake said while Miss Young's heart was monitored appropriately in the emergency department, nursing staff "did not give any handover and certainly no instructions about cardiac monitoring" when she was transferred to another was later found unresponsive and attempts to resuscitate her coroner said Miss Young had a chance to take another overdose, as staff found more of her medication in her belongings after she it was not known if she had taken more James Paget has until 20 August to tell the coroner what plans of action it has put in place. Follow Norfolk news on BBC Sounds, Facebook, Instagram and X.
Irish Times
03-07-2025
- Health
- Irish Times
Mother whose baby died five days after birth satisfied ‘fair and just process' followed with second inquest
A mother whose baby died five days after birth has said she is now satisfied that a 'fair and just process was followed' after a second inquest into his death examined previously undisclosed evidence. Claire Cullen, who cofounded Safer Births Ireland, secured evidence surrounding concerns over equipment used in her son Aaron's resuscitation after he was delivered by emergency Caesarean section at Midland Regional Hospital Portlaoise in May 2016. This evidence, which she obtained through freedom of information requests, sparked a fresh inquiry as it was not made available to an initial inquest which returned a narrative verdict in 2019. A narrative verdict was returned by coroner Dr Myra Cullinane on Thursday for a second time, incorporating the new evidence, before she recommended that all information relating to a death being investigated by a coroner 'be disclosed in full and at the earliest opportunity'. READ MORE Dr Cullinane said the recommendation was made 'to prevent anyone else from going through what we have had to go through'. Providing new evidence, nurse Elaine Sheehy told the inquest on Wednesday that the flow of gas through a 'Neopuff' resuscitator used to provide oxygen to Aaron during his first 11 minutes of life was at a low level until she arrived. Unable to breathe after birth, the Neopuff resuscitator was used between two failed intubation attempts. He was ultimately intubated at 21 minutes of age once a paediatric consultant arrived. Ms Sheehy also recalled a full-term mask being used which was too large for Aaron, who was born at 35 weeks. After corrective actions, Ms Sheehy said Aaron's heart rate improved and the machine began to record oxygen saturation. However, the inquest heard on Thursday that Aaron was 'already in extremis' immediately after his birth, and had been suffering from severe and persistent pulmonary hypertension, a condition in which a baby fails to transition from antenatal circulation. This, which was noted as being caused by systemic thrombosis, was the ultimate cause of his death. Dr Paul Downey, a consultant perinatal pathologist, said thrombosis found in Aaron's left kidney was heavily calcified suggesting it was 'well established' before birth. The systemic thrombosis was noted as being in association with a non-lethal mitochondrial disorder, from which the inquest heard just 30 people are known to suffer worldwide. Dr Downey said it was unclear whether there was an issue with oxygen delivery during part of the resuscitation; however, if that was the case, it was his opinion that it did not cause his death. 'That's not to say it didn't have any effect, but I don't think it caused his death,' he said. Before a verdict was delivered, Fiona Gallagher, counsel for the family, said the failure to disclose Ms Sheehy's concerns as evidence exacerbated the 'trauma and distress' the family has suffered. Counsel for the HSE, Luán Ó Braonáin, submitted that evidence heard this week points to a death of natural causes, saying it would be in the discretion of the coroner to find such a verdict. Speaking outside the court, Claire Cullen said her nine-year fight has 'finally reached a conclusion'. She said her son's rights were 'hindered and impacted throughout every investigative process' into his death. Ms Cullen believed if she had not sought further information, 'it would have never been disclosed to me'. 'Six years ago, we left the coroner's court with more questions than answers,' she said, adding that she is now satisfied it has had the opportunity to be fully investigated. 'Today, I leave the coroner's court knowing that I did everything in my power to offer my son the dignity and respect as a human being that he deserved,' she said.
Irish Times
01-07-2025
- Health
- Irish Times
Family settles action against pharmacy after mother allegedly died from wrong medication
The family of a woman who allegedly died after taking medicine supplied by her local pharmacy that was intended for another customer has settled a High Court action over her death. Margaret Corcoran (73), a mother of two and grandmother of six, was found in a collapsed state at her home in Tymonville Park, Tallaght, Dublin on October 9th, 2022. She was transferred to hospital where she was found to have suffered a brain injury. Ms Corcoran did not recover and died in hospital 11 days later. Ms Corcoran's sister, Marian Reilly, of Lucan, Dublin, sued Glenview Pharmacy Ltd with a registered address at Upper Baggot Street, Dublin, trading as Meaghers Pharmacy. READ MORE The family's barrister, Esther Earley, instructed by O'Brien & Co solicitors, told the High Court this week the case had been settled. There was no admission of liability. In the proceedings, it was claimed that a blister pack of medication prescribed for another person with the same first name was mistakenly delivered to Ms Corcoran six days before she was found collapsed in her home. On October 3rd, 2022, it was claimed a blister pack of tablets was prepared at Meaghers Pharmacy, Castletymon Park Shopping Centre, Tymon Road, Tallaght for dispatch to Ms Corcoran, but that an incorrect pack, meant for someone else, was sent instead.. It was claimed there was an alleged failure to exercise the appropriate level of care, skill and diligence that Ms Corcoran was entitled to expect in relation to the prescription medication being sent to her home. It was also claimed there was a failure to haveany adequate system of checks and safeguards in place to ensure that prescriptions and medication dispensed were checked and rechecked.. The case contended there was a failure to contact Ms Corcoran urgently, or at all, to ensure she did not consume the medication when they ought to have known the significant risks it posed for her. At Ms Corcoran's inquest in March, 2024, her sister Ms Reilly described finding her on the ground beside her bed in an unresponsive state and 'frothing from her mouth'. At the inquest, a representative of Meaghers Pharmacy Group offered the company's 'most heartfelt condolences' to Ms Corcoran's family. She said the pharmacy only became aware the wrong medication had been given to Ms Corcoran after it had been contacted by a nurse following her admission to hospital. The Coroner's Court also heard that storage at the nine Meaghers Pharmacy outlets was subsequently rearranged, with labels on all prescription bags now double checked by two staff members including a pharmacist. A verdict of death by misadventure was returned.
