Hospital apologise after treatment fell "below the required standard"

Inquest hears of delayed diagnosis

The management at Cavan General Hospital have apologised to the family of a woman whose treatment fell “below the required standard” after an inquest heard of a delayed diagnosis of a perforated ulcer.

The woman, aged in her 70s, died in April 2022, just two days after admission. An inquest, held at Cavan Courthouse last week, returned a narrative verdict (see page 10 of this week's Celt newspaper for full report).

The woman arrived at Cavan General by ambulance on April 18, 2022, with symptoms consistent with an upper gastrointestinal bleed. A Category 1 patient, ED staff repeatedly sought an urgent surgical review, but neither the surgical registrar nor the on-call consultant physically assessed her.

A chest X-ray was initially deemed “normal”, but the following morning a consultant physician spotted air “beneath the diaphragm” - a sign of a perforated duodenal ulcer. However, at that point she was deemed unfit for surgery.

The woman was eventually placed on palliative care and later died.

Coroner Dr Mary Flanagan found there was a “missed opportunity” to diagnose, and further missed opportunities in communication with the on-call surgical consultant and surgical team.

Counsel for the hospital, Conor Halpin SC, told the inquest that an internal review had taken place. All recommendations have since “been implemented”. These include a new ED referral pathway, a mandatory escalation policy, closer monitoring of referral delays, and a revised Intensive Care Unit referral and admission procedures.

In a statement to The Anglo-Celt, a spokesperson for the HSE said Cavan and Monaghan Hospital extend “our heartfelt sympathies and condolences” to the deceased’s family.

“We can confirm that a review was undertaken,” they detailed. “All recommendations arising from this review have been fully implemented.”