Critical scan info 'fell out' in handover
A coroner has called for the immediate implementation of all recommendations arising from a critical review into the death of a woman at Cavan General Hospital almost two and a half years ago.
Jean (Mary Jane) Lamb (née Ryan), of Rooskey Vale, Monaghan Town, and formerly of Cathedral View, Monaghan, and Thurles, Co Tipperary, was remembered at last week’s inquest by her daughter Lorraine as “a person filled with life”. Only weeks earlier, the court heard, the 80 year old had celebrated her birthday, delighting family and friends when she arrived with her hair dyed pink.
Ms Lamb suffered a fall and a minor brain bleed several days before being admitted to Cavan General Hospital, where she collapsed just hours before her death on April 23, 2023.
Her inquest, held at Cavan Courthouse last week, heard evidence of “serious system failures” in the handover of clinical and medical information between shifts. These failures resulted in a missed blood review and the inappropriate and over-prescribing of an anticoagulant. The medication acted as an “accelerant” on what had initially been a minor bleed, the hearing was told.
County Coroner Dr Mary Flanagan recorded a verdict of 'death by medical misadventure'.
Following a fall at her home on April 15, 2023, Mrs Lamb attended her GP and was prescribed an antibiotic. However, she continued to appear unusually sleepy - a change in demeanour that prompted her daughter Lorraine to call an ambulance, which transported her to Cavan General on April 18.
Mrs Lamb's family was represented by John Sweetman BL, instructed by Freda Murphy of PPN Litigation Solicitors.
“I knew she needed help,” said Lorraine of her mother.
Doctors at Cavan’s Emergency Department assessed Ms Lamb using the Glasgow Coma Scale, which was recorded as “normal”. Yet visible bruising on her face - stemming from a fractured eye socket - and complaints of pain on her side raised concern, and a CT scan was ordered. It revealed a developing bleed inside her skull. The neurosurgical team at Dublin’s Beaumont Hospital was contacted and recommended the anticoagulant Ms Lamb was taking, warfarin, be stopped.
They further instructed that her International Normalised Ratio (INR) be kept under 1.5, that she undergo a repeat CT scan in one week, and receive a haematology referral due to her anticoagulation status. All of this was properly documented in her surgical transfer file to the Emergency Department, the coroner later confirmed.
Ms Lamb was eventually placed on a ward bed after being admitted by the medical team. On a call, Ms Lamb’s daughter said her mother appeared “confused”, asking about booking an aqua aerobics class - something they had not attended in months.
But on the day before she died, Ms Lamb seemed in “good form”.
“There was no way she didn't think she was getting home,” said Lorraine.
It was a call from the guards in the early hours of Sunday, April 23, 2023, that informed the Lamb family of the developing emergency. Ms Lamb had collapsed while sitting on the edge of her bed, and a new CT scan showed her suffering from a “massive” brain bleed.
“It's something that will stay with me for the rest of my life - watching my mother die,” Lorraine told the inquest, recalling in vivid detail that her mother was still wearing the same colour nail varnish as on her 80th birthday.
“My mother loved life. She smiled from when she got up in the morning until she went to bed. I never knew someone to take so much out of the day... Even spending 10 minutes in her company made you feel better.”
Dr Wardeh Jabeen, Surgical Senior House Officer, confirmed the referral made to Beaumont and the advice received by doctors in Cavan, which was then transferred into the ED notes.
Dr Elwalead Salah, Senior House Officer on call at Cavan A&E when Ms Lamb was admitted, was aware of her head injury and of the recommendation to stop warfarin for one week, but not of the need for a haematology review.
Mr Sweetman questioned whether this information simply “fell out”.
“Is it possible you didn't see it?” he asked.
“I can't remember exactly,” replied Dr Salah.
Dr Fazlullah Kahn reviewed Ms Lamb's condition on April 21. He spoke to a consultant two days later, and it was decided to place Ms Lamb on apixaban, an alternative blood-thinning medication. Ms Lamb’s INR was above two when she was prescribed the drug - outside the guidelines for her age and renal function. The reading had been 2.3 the previous day, according to her file.
Dr Kahn said he did not remember speaking with Dr Salah in the handover, nor was he aware of the advice from Beaumont Hospital.
David Broughton BL, instructed by Mason, Hayes and Curran Solicitors on behalf of the HSE and the hospital, suggested the inquest was not in a position to infer any perceived “lack of awareness” of the advice provided by Beaumont.
Dr Muhammad Hussein said apixaban was administered due to the potential risk that Ms Lamb might suffer a stroke. He was working as a locum for Consultant Physician Dr Paulo Pinheiro at the time. He said he had looked at the earlier CT scan but was “not aware” of Ms Lamb's brain bleed. He also stated he was not aware of the engagement with the neurosurgical team at Beaumont, the reasons for stopping warfarin, or had any recollection of the haematology referral.
Asked how he might have reacted had he known all of this information, Dr Hussein stressed that each patient is treated on a “case by case” basis.
“All the information was available at your fingertips and it wasn't reviewed correctly,” said Mr Sweetman in cross-examination.
Dr Hussein stressed again that doctors treat every case “separately”.
The nurse treating Ms Lamb on the ward the night she collapsed said the deceased had been feeling nauseous and she went to get medication for her at around 3am. On her return, she found Ms Lamb lying face down on the floor with a cut to her head. She contacted the senior consultants on call, Ms Lamb was transferred back to her bed, and an urgent CT scan was ordered. At 7:25am she was transferred to ICU with a verbal handover concerning her condition given.
Dr Saheed Rizwan Bukhari had his deposition read out by Dr Flanagan. He had been in A&E when he was bleeped to attend Ms Lamb in Medical 2. He was alarmed that anticoagulant medication had been recommenced. Once again, Beaumont Hospital was contacted. Dr Bashir Abdukhadir said the same doctor who had earlier advised Cavan staff returned the call. The new scan showed signs of catastrophic intracranial pressure, with surgical intervention no longer possible.
Mrs Lamb’s condition continued to decline, and her time of death was recorded at 10:55am.
A post-mortem was carried out April 23 at Navan Hospital by Dr Muna Sabah, who found the cause of death to be intracranial pressure due to subdural haematoma. She said the bleed Ms Lamb was admitted was not made worse by her second fall.
“She fell because she lost consciousness because the haematoma was actively beginning to compress on the brain.” This, the pathologist noted, was “exacerbated” by the presence of an anticoagulant, which had acted as an “accelerant” to the bleed.
“There was no accident in this case, it's not an accident,” Dr Flanagan declared in response to submissions made by Mr Broughton on behalf of the HSE and hospital regarding the verdict. She instead described the incident as a “progression of events” arising after the initial CT scan was performed that “were not acted upon”.
She further acknowledged the pathologist’s evidence that the venous bleeding inside Ms Lamb’s brain was “exacerbated” by the anticoagulant, administered at a dose and timing that increased the danger rather than mitigating it.
“I believe that medical misadventure is the appropriate verdict under the circumstances,” stated Dr Flanagan, thanking those who made submissions and offering her deepest sympathies to the Lamb family.
Her recommendations arising include that the hospital strengthen its systems to ensure “clear and safe” ownership of patients presenting to the Emergency Department, and that Non-Consultant Hospital Doctors should seek senior physician input when managing “complex cases”. She also requested that “robust” systems be put in place to ensure that daily multidisciplinary handovers “capture” all essential medical and clinical information, including plans of care so that consultants are made aware of any significant investigative findings before determining or altering management plans. Furthermore, transitions between anticoagulants must follow national and local guidelines.