Re: The Late Kathleen Conroy deceased
Date of Death: 28 th March 2014
Date of Conclusion of Inquest: 23 rd May 2016
Date of Conclusion of Medical Negligence Action: 29th November 2019
At the outset, we express our sympathies to the family of the late Kathleen Conroy. We have worked with that family over a period of five years to achieve clarity as to the events that resulted in Kathleen’s untimely death and to achieve justice in relation to the circumstances surrounding that death and indeed, to achieve fair recompense in financial terms.
The late Kathleen Conroy presented at the Emergency Department of Beaumont Hospital with a classic history of short distance DVT of relatively recent onset and persistent pain in her right leg.
For some unknown reason, Beaumont Hospital Emergency Department personnel excluded a deep vein thrombosis, given the strong family history but acute arterial thrombosis was not excluded. Accordingly, if Kathleen Conroy had been admitted on either of her two presentations to the Emergency Department and commenced on intravenous heparin it is probable that extensive thrombosis within the aorta would not have developed. The failure to consider a CT or MRI scan based upon the symptoms at date of presentation and the clinical indicators that existed on 24 th March 2014 resulted in a missed opportunity to save her life.
Failure to Diagnose DVT
If her presentation had been looked at in the context of the progression of her illness since the date of her original presentation, it ought to have been appreciated that there was an urgency associated with a DVT that needed proactively to be addressed. In addition, when matters were addressed, there was a failure to communicate the result of an echocardiogram completed on 28 th March 2014 which revealed an ejection fraction of 20%. This was probably a critical failure as it would have highlighted to the Vascular Team and Consultant Radiologist that there was a significant risk of complications developing during the proposed surgical procedure. Obviously, the first opportunity to address matters had been missed by the Emergency Team and an opportunity to minimise inappropriate life risk during the belated surgical procedure that then was critical failed to occur. It would have been prudent to have had additional clinical staff such as an Anaesthetist present during the procedure in order to monitor Kathleen Conroy and treat any adverse metabolic and cardiovascular responses. That did not occur.
Lack of Hospital Bed
A further failure that existed in the unfolding emergency situation that was occurring was the inability of Beaumont Hospital to identify an appropriate High Observation bed in a timely fashion which further delayed the surgical procedure contemplated. This delay occurred
because of pressure on the existing Beaumont Hospital beds and because of the requirement for a bed in the most appropriate setting i.e. a High Observation bed in a Vascular Ward.
Further failures occurred in terms of communication breakdown throughout Kathleen Conroy’s admission which were referred to in the course of the Inquest that was concluded on 23rd May 2016.
An extraordinary event occurred in that an electrical power outage on the anaesthetic pendant occurred when the angiojet was plugged into the isolated power supply main socket on the pendant. The electrical power outage on the pendant removed the power supply to Kathleen Conroy’s vital sign monitor. The Team continued to advance the procedure once power to the angiojet was re-established at a wall socket. Such an event of power failure in an essential piece of equipment would inevitably have caused significant disturbance, loss of concentration and was undoubtedly adverse to the patient’s interests in the context of what was at that time a serious surgical procedure due to the pre-existing delays that had occurred.
Admission of Liability
On 14th November 2019, Beaumont Hospital not only admitted liability to the family of Kathleen Conroy but apologised for the tragic events that led to the death of the late Kathleen Conroy.
In that regard, Rónán Dolan S.C. on behalf of Beaumont Hospital read out an apology signed by Ian Carter, Chief Executive of that Hospital in the following terms: – “On behalf of Beaumont Hospital, I wish to apologise sincerely for the deficiencies in care that led to the untimely death of your mother, Mrs. Kathleen Conroy. I wish to further apologise for the distress experienced by your family as a result of the loss of your mother and the miscommunications that occurred at this difficult time for your family. I wish to extend my deepest condolences on behalf of the staff of Beaumont Hospital to each of you.”
It should be noted that a verdict of medical misadventure was delivered in relation to the circumstances of death of the late Kathleen Conroy at an Inquest held by the Dublin City Coroner concluded on 23rd May 2016. That Inquest heard three days of evidence in the context of the tragic events that led up to the death of the said Kathleen Conroy.
Malcomson Law wish to be associated with the comments of Kathleen Conroy’s family where, that family indicated that it is hoped that lessons will be learnt from this sequence of medical errors causing their mother’s death to avoid a repetition of a similar tragedy and heartache for any further families.
Link to RTE article: https://www.rte.ie/news/courts/2019/1129/1095970-kathleen-conroy/