"Marian’s death wasn’t in vain": Inquest returns verdict of medical misadventure

A doctor on call was contacted four times by staff who had concerns for a patient who later died, an inquest has heard.

A verdict of medical misadventure was returned at the inquest into the death of Marian Tracy (60).

She died four days after surgery to remove her thyroid was performed on May 14 2015.

Ms Tracy of Dodsboro Road, Lucan, County Dublin died due to lack of oxygen to the brain due to compression of the windpipe due to a clot following thyroidectomy surgery at St James’s Hospital.

In a statement read out after the inquest, the Tracy family said they are devastated by her loss.

“Marian was the heart of our family and her death has left a huge void in all our lives. We would hope that Marian’s death wasn’t in vain and the coroner’s recommendations be put in place and hopefully prevent another family having to suffer as we have.”

ENT (ear, nose and throat) registrar-on-call Dr Monica Istovan was contacted four times by hospital staff and an intern doctor relaying concerns for the patient between 6.30pm and 11.04pm on May 15 2015.

The registrar-on-call did not attend the patient in a private ward in hospital until after Mrs Tracy had suffered a respiratory arrest, Dublin Coroner’s Court heard.

Concluding a two day inquest into her death, Coroner Dr Myra Cullinane recommended that St James’s Hospital and the Health Service Executive review their position of consultants operating on-call services to multiple hospitals and consider having senior on-call staff on-site within the hospital.

The coroner recommended that hospital staff across all levels be enabled to contact senior staff directly and that neck swelling post thyroid surgery prompt early review by ENT staff.

Mrs Tracy developed neck swelling, difficulty swallowing and breathing the day after her surgery to remove her thyroid, the inquest heard.

Night nurse Sarah Keating contacted Dr Istovan, who was at home when she received the call at 9.45pm.

“I was worried because I had never seen a patient post-operative with this level of swelling,” Nurse Keating told the court. Dr Istovan instructed the nurse to ask the surgical intern on call, Dr Michael Dowling to assess the patient.

Asked if there was any way to over-rule the instructions of the registrar-on-call, the nurse replied:

“It’s not really my call. It’s at her discretion.”

Dr Dowling reviewed the patient and he was asked to send pictures of the patient’s wound to Dr Istovan’s phone. When she saw the pictures, the registrar-on-call said she would come in to see the patient. Sara Antoniotti, barrister for the family asked about the sending of pictures by phone.

“In this situation, we felt it was the only option at the time and we were taking direction from the ENT registrar-on-call,” Nurse Keating said.

Shortly afterwards, Mrs Tracy went into respiratory arrest. She died three days later on May 18.

The coroner returned a verdict of medical misadventure and the hospital apologised to the family for the failings in Mrs Tracy’s care.


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