‘Mr Lawlor was let down... that shouldn’t have happened’
A series of “systems failures” at Cavan General Hospital led to the missed diagnosis of a brain tumour, which grew four times in size in a matter of months and ultimately caused a man’s death.
Martin Lawlor’s inquest heard of multiple “missed opportunities” to pick up the clinical oversight, as well as a near 15-year wait for an IT solution, and other concerns over delays when crucial scanning equipment breaks down.
Mr Lawlor (71) died surrounded by his loving family at Cavan General (CGH) on September 23, 2016.
His wife Patricia, who attended the hearing at Cavan Courthouse last Wednesday (October 2), described her late husband as her “soulmate” and “perfect in every way”.
She recalled before coroner Dr Mary Flanagan, who recorded a ‘Narrative’ verdict, that Mr Lawlor was admitted to CGH in mid May 2016.
In 2000, Mr Lawlor, a native of Dublin, was among the first in Ireland to undergo a successful heart transplant. As a result, he was also under the care of the cardiac unit at the Mater Hospital.
An MRI was carried out on Mr Lawlor’s brain on May 31, 2016 and Ms Lawlor stated her belief her husband was “not fit to be discharged” as he was later that day.
She noticed a “change” in his personality. He had “become paranoid”, she told the inquest.
Ms Lawlor remembered too bringing her husband back to hospital just months after, in September, when she was told palliative care was the only option recommended.
“I’m grateful for the man he was,” said Ms Lawlor who, with her family, was represented by Ciaran Tansey, lead advocate with Damien Tansey Solicitors.
He had described it as “groundhog day”, dealing with yet another hospital inquest where problems with the IT system figured so prominently.
“It’s frightening,” said Mr Tansey.
Cavan General, and the HSE, were in turn represented by David Broughton BL, instructed by legal firm Mason, Hayes and Curran.
The statement of Dr Kilian O’Rourke, consultant at the Mater Hospital, recalled Mr Lawlor being admitted in June 2015. Mr Lawlor had fallen in the garden at his Carrickabruise home near Virginia three months previous. The night before admission he fell again, this time in the bathroom.
An MRI and a lumbar puncture were carried out. The MRI revealed “white matter changes” in Mr Lawlor’s brain, and also lateral disc protrusion in his spine.
His admission to CGH the following year was from May 19-31.
His MRI on his final day there, Dr O’Rourke said, showed up an “abnormality” on Mr Lawlor’s left temporal lobe. The growth was 1.5 cm in size, the inquest would hear.
He received another MRI on September 9, when the tumour had grown to a size of six by five centimetres.
Mr Lawlor died almost a fortnight later.
Professor James Hayes said Mr Lawlor was admitted to CGH with reports of “lethargy and drowsiness”.
His apparent “agitation” at CGH was put down to “delirium” and a CT scan of Mr Lawlor’s brain appeared “normal”. A follow up MRI was booked for the following day.
Prof Hayes then went on annual leave, and Mr Lawlor’s file was handed over to a locum in charge.
Prof Hayes says he was never made aware of the apparent “lesion” on the left front side of Mr Lawlor’s brain.
There had been a “failure” to report the discovery, and he apologised to Mr Lawlor’s family for the missed diagnosis.
Both the CT scan and the MRI carried out a year earlier had appeared “normal”.
But the later scans should have been fed through a “peer review” system, and this simply “didn’t happen”.
Mr Lawlor was discharged the same day as his May 2016 MRI took place, and within minutes of the results being made available.
In cross-examination Mr Tansey asked why it had taken so long for Mr Lawlor to get an MRI after his initial admission.
Prof Hayes said there was just one such scanner at CGH, which was paid for following the death of a benefactor in New York. The CT scanner has also been paid for through local fundraising.
Only last week did the MRI scanner break down. “They’re expensive to buy, and expensive to maintain,” stated Prof Hayes.
It was noted that Mr Lawlor’s discharge passed through the hands of two senior doctors, and still the apparent growth on his brain was not picked up.
It was explained that, once scans are complete, emails are sent to the treating physician who then cross references the imaging with a separate system. There could be dozens, and while there is an option to print, there is currently no way of “ticking” off those checked or not.
“That seems very unwieldy and unmanageable,” remarked Dr Flanagan.
“Yes it is,” agreed Prof Hayes, who suggested the doctor may have looked at Mr Lawlor’s CT scan and not the MRI.
“Mr Lawlor was let down by us and that shouldn’t have happened,” acknowledged Prof Hayes.
A review was carried out in the wake of Mr Lawlor’s death and learnings taken from it, the inquest was informed.
Clinical Director and Consultant Radiologist at CGH, Val Gough, was part of the review team that looked at the case after Mr Lawlor had passed away.
Dr Gough also offered his apologies on behalf of the hospital to Mr Lawlor’s bereaved family.
He told Mr Tansey that, had he noticed the lesion, he would have “rang or texted” the consultant involved.
Asked whether Mr Lawlor’s case should have been peer reviewed, Dr Gough said: “Probably yes.”
From studying and comparing the scans from May and September 2016, he pointed out that the tumour presented as “very aggressive”, but an alert “was not triggered”.
He said there is an “expectation” inpatient scans are being read.
“If they’re sick enough to be there, and get the scan, they’re sick enough to have it read.”
Outpatients otherwise get their scans read within a period of six days, based on a three-tier system used nationally that categorises cases as ‘Urgent’, ‘Critical’, and lastly ‘Unexpected/Clinically significant’.
“Everyone is unexpected and everyone is significant,” he noted, adding that the majority of inpatient cases fall within ‘clinically significant’.
Dr Gough also expressed the opinion that to peer review every case would negate its effectiveness.
He informed the inquest that HSE hospitals were “promised” the new ‘Ordercom’ IT system as far back as 2011, providing consultants with a “tick box” option. The delay was partly due to cyberattacks on the HSE and in Canada where the company providing the software upgrade is based, and then Covid.
Indications are the roll-out will begin in Limerick in early 2026, and in Cavan not before three years’ time.
Regarding the MRI machine breaking down, Dr Gough revealed that €1 million has been allocated to a complete a full refurbishment of the scanner “before the end of the year”.
The hospital has now also tightened up its patient systems, with doctors and radiologists encouraged to raise concerns at weekly Multi-Disciplinary Team meetings.
“They’re well established, there’s a good attendance,” said Dr Gough of those Friday gatherings.
The last witness was Consultant Physician, Dr Paulo Pinheiro, and he provided an account of the care Mr Lawlor received from his admission in September 2016 until his death.
Mr Lawlor was admitted to ICU. He was “not fit” for invasive therapy, and Dr Pinheiro doubted whether invasive intervention would have elongated the patient’s lifespan, perhaps only by between a week and four weeks. This too would have had side effects.
Instead, by managing his pain and comfort, Dr Pinheiro said Mr Lawlor’s family were able to even celebrate Dublin winning the All-Ireland by his side.
He was more certain the scan would have been checked, but still accepted “there are so many variables”.
“We are trying to fill the gaps.”
In his closing remarks, Mr Tansey asked for a verdict of death by medical misadventure.
He spoke of the multiple “missteps”, and the need for a new system that will “protect” doctors and their patients.
The inquest was told that Mr Lawlor’s family was anxious that nobody, nor their families, should have to go through a situation like that which occurred.
Dr Flanagan agreed with Mr Boughton’s recommendation that a more “appropriate” account is summed up by a ‘Narrative’ decision.
She recorded that Mr Lawlor died from a brain tumour where an MRI was carried out on May 31, 2016, but there appeared to be “no follow up”. She recounted that Mr Lawlor was readmitted in September that same year when another scan revealed the growth had increased in size.
Dr Flanagan said she did not like to state there had been “systems failures” in the context of an inquest, but remarked: “Doctors didn’t follow up on [on the scans] and there is no way of getting around that.”
She concluded by saying there had been “system failures” and as per a rider, based on the recommendations of Mr Lawlor’s family, committed to writing to the HSE and CGH asking that the new IT upgrade be implemented with the utmost urgency.
Additional reporting
We have been asked to point out, and we confirm, that Dr Gough did not personally report on any of the scans on Mr Lawlor and did not have active clinical involvement in his care. After Mr Lawlor's death, Dr Gough, on request, participated in the hospital review process, finding that the scan at the time of Mr Lawlor's initial presentation had been reported by the reporting radiologist in a timely manner.
Unfortunately, as the coroner recorded, doctors did not then follow up on the scan.
Dr Gough was in attendance to assist the hearing as the reporting nueroradiologist was unavailable being outside Ireland.