Missed opportunities identified in hospital death

Narrative verdict recorded at inquest

A narrative verdict has been returned at an inquest into the death of a woman at Cavan General after a perforated duodenal ulcer was not diagnosed until the morning after her admission.

The hearing at Cavan Courthouse on Thursday, June 26, heard the woman, aged in her 70s, was brought to the local hospital by ambulance on the evening of April 18, 2022.

Vomiting “coffee-ground” material and displaying other symptoms consistent with an upper gastrointestinal bleed, she arrived shortly before 8pm and was triaged as a Category 1 emergency patient requiring immediate assessment.

Emergency Department staff found the woman to be in “shock”, with a rapid heart rate, low blood pressure, severe anaemia, “very low” haemoglobin and low blood glucose. She was unconscious on arrival, and her medical history was provided by ambulance personnel.

Dr Ali Kahn, Emergency Department (ED) registrar, told the inquest by video link the belief was the woman had a possible upper gastrointestinal (GI) bleed. He said repeated attempts were made to contact the on-call surgical team between the woman’s arrival and approximately 10pm. During that period she underwent resuscitation with intravenous fluids, blood products and other supportive treatment while further investigations were carried out.

A chest X-ray performed shortly after admission was interpreted by Dr Kahn as “normal”.

“At the time I wasn’t able to see anything of concern,” he said.

The ED team continued to seek a surgical review.

Asked by Coroner Dr Mary Flanagan about his “working diagnosis”, Dr Kahn said it remained focused on a possible GI bleed.

Despite several attempts neither the surgical registrar nor the on-call consultant attended the ED. When contact was eventually established, Dr Kahn was told the surgical team was “very busy”. Following further discussions by telephone, the surgical team concluded the woman should be admitted under the medical team, believing sepsis to be the more likely diagnosis.

Consultant in Emergency Medicine, Dr Irfan Ahmed, told the inquest he attended the hospital after being contacted by his registrar, Dr Haroon Ilyas, regarding the patient’s condition and the unsuccessful attempts to secure surgical involvement.

ATTEMPTS TO CONTACT SURGICAL CONSULTANT

Dr Ahmed made a number of attempts to contact the on-call surgical consultant, Dr Pawan Rajpal, to discuss the woman’s condition and appropriate care. He also consulted anaesthetist Dr Ishan Butt. However, as the patient’s condition had become increasingly “unstable”, she was referred for high dependency care.

Dr Ilyas said the Surgical Registrar, Dr Syed Waqas Ali Bukhari, had contacted him wanting him to discuss admitting the patient under medical. Their belief was the woman had sepsis. Dr Ilyas said he had not personally reviewed the patient but was informed by medical colleagues that surgical “should be able to handle the case, even if sepsis was present”.

Medical registrar Dr Ahmed Fawad, now a Special Lecturer and Clinical Tutor at the UCD School of Medicine, told the inquest he had “reflected deeply” on the circumstances surrounding the woman’s treatment.

He was contacted by Dr Ilyas regarding the surgical team wanting to have the patient admitted under medical care. He was not specifically asked to assess her in person, but was informed she had a suspected upper GI bleed, and that the chest X-ray had been reported as “normal”.

Dr Fawad said he attempted to review the imaging himself, but the hospital computer system “crashed” before the images could be properly uploaded. He resigned himself to looking at them again later.

He told the hearing that admitting the patient formally would have required consultant involvement.

In his opinion, Dr Fawad did not believe sepsis was the most likely diagnosis, and he requested further clinical information. He also witnessed the ED consultant attempting to contact the surgical team while conducting ward rounds.

It was accepted the patient could not remain indefinitely in the ED, and she was eventually admitted under the medical team while continuing to receive intensive resuscitation. Following review by the anaesthetic team, she was transferred to the Coronary Care Unit, where her blood pressure and other clinical markers temporarily “improved”.

The following morning, at approximately 8am, Dr Fawad was present when consultant physician Dr Muhammad Hussein reviewed the admission chest X-ray with radiology and identified air beneath the diaphragm - a sign of a perforated duodenal ulcer not recognised when the X-ray was initially interpreted.

Dr Hussein’s deposition was read into the record. Fellow Medical Consultant physician Dr Azam Jawid subsequently told the hearing that he contacted Dr Rajpal, who accepted that emergency surgery was required.

Beaumont Hospital was approached regarding an emergency transfer to Dublin but advised the patient was too clinically unstable for transfer and surgery, if feasible, should instead be carried out “locally”.

Consultant anaesthesiologist Dr Ishan Butt, the final witness, said he was in ED with another patient at about 1:30am when asked to review the woman. At that stage he suggested an endoscopy to identify the source of the suspected bleed.

NOT FIT FOR SURGERY

However, following further discussions between the surgical and anaesthetic teams later that morning, it was concluded the woman’s condition had deteriorated to the point where she was “no longer fit” to undergo surgery.

A CT scan performed nearly four hours after that confirmed a perforated duodenal ulcer.

The inquest heard that antibiotics were not administered during the early stages of the mum of three’s admission despite sepsis being a possible diagnosis. Antibiotic treatment commenced only after the perforated ulcer was confirmed, by which time she was regarded as too unwell for either surgery or transfer.

Dr Jawid subsequently referred the patient for palliative care. She died at Cavan General Hospital on the morning of April 20, 2022.

Neither Dr Rajpal nor Dr Bukhari attended the inquest to give evidence.

Delivering her findings, Dr Flanagan said the woman had been ill on arrival but found there had been a “missed opportunity” to diagnose the perforated duodenal ulcer when radiological signs were already visible on the initial chest X-ray. She also identified further missed opportunities in communication with the on-call surgical consultant, who was unavailable to give evidence during the hearing.

RECOMMENDATIONS

Following the verdict, counsel for the hospital, Conor Halpin SC, instructed by Mason, Hayes & Curran Solicitors, confirmed an internal review conducted after the woman’s death resulted in a number of recommendations, all of which had since been implemented.

These included a revised Emergency Department referral pathway (by Q4 2022), a mandatory escalation policy requiring alternative consultants within the same speciality to be contacted when the on-call consultant is unavailable, enhanced monitoring of referral delays through clinical governance structures, and updated Intensive Care Unit referral and admission procedures (Q1 2026).

The hearing was told the measures remain subject to ongoing audit and governance review.

An apology first issued by Cavan General Hospital to the family in 2023 was formally reiterated during the inquest. In the statement from Laura Waters, General Manager at Cavan General Hospital, read by Mr Halpin, management acknowledged that aspects of the woman’s care had fallen “below the standard” she and her family were entitled to expect and expressed their sincere condolences.

The inquest arose following a referral by the hospital’s Clinical Director to the coroner in May 2023 after concluding that aspects of the care provided “may have contributed” to the woman’s death.