University Hospital Limerick hospital has “apologised sincerely and unreservedly” to the family of a teenage girl who died after sustaining massive blood loss and an injury to her aorta, during a routine surgery.
Jessica Sheedy (18) from Bruff, Co Limerick, was admitted to UHL on May 8th, 2018, to have a benign tumour removed from her abdomen.
During the procedure she sustained a “significant bleed”, loosing a total of seven litres of blood.
Ms Sheedy died three days later on May 11th, in the hospital’s High Dependency Unit, from “multi-organ failure secondary to the removal of the tumour”, a post mortem concluded.
Several theatre staff who were assisting Ms Sheedy’s surgeon, Mr Ashish Lal, gave evidence that following the bleed, he refused to act on their repeated calls to seek assistance from vascular consultant surgeons.
Catherine Browne, a theatre nurse who was assisting Mr Lal said during the surgery she “witnessed a huge gush of blood” “filling up” inside Ms Sheedy’s abdomen.
She claimed “Mr Lal refused” offers from her to get other surgeons to help him. She said she asked him if he needed help, but, “he said no”.
Theatre nurse, Elaine Lyons, said she also asked Mr Lal if he needed help, but that “he said no”.
She said she telephoned on-call consultant vascular surgeon, Mr Eamon Kavanagh, and told him, “we are in trouble in Theatre Six, Mr Lal is refusing help”.
“Mr Lal said he didn't want any help,” she told the inquest before returning to her seat and broke down in tears.
Dr Eoin Fahey, who also assisted Mr Lal, said there was “a sudden rush of arterial blood” during the operation, and Ms Sheedy’s blood pressure “dropped rapidly”.
He said theatre staff in the room had “sought help”.
Dr Helen Earley, a junior registrar, said she also asked Mr Lal “if he needed help, and he said no”.
She said she remembered Ms Lyons asking Mr Lal “more than once”.
She added that, if she had been performing the surgery, her “response would have been to call for help from another vascular surgeon, but I was just a junior trainee”.
Mr Kavanagh said “a major transfusion protocol was activated” which involved the team contacting the bloodbank for extra blood.
This happened 20 minutes after the “significant bleed”.
About forty minutes after the bleed, Mr Kavanagh arrived and carried out a “repair to the aorta”.
Mr Kavanagh said he was “very surprised” to get a call from Ms Lyons, as he “had no prior knowledge” of the surgery.
He agreed it was “usual” he would have been consulted prior to similar surgeries, and that it would have been usual that vascular surgical support would be arranged to have been on standby.
Before reading his deposition into evidence, Mr Lal, offered his “deepest sympathy and condolences” to the Sheedy family.
“Not a day has gone by in the last 18 months that I haven’t thought about Jessica,” he said.
Mr Lal said he “could not see where the blood was coming from” and he had concentrated his efforts on removing the tumour, as he felt it was “obscuring” his view of the location of the bleed.
He said he eventually requested help from other surgeons.
Mr Kavanagh identified the source of the bleed, as a hole on the aorta.
“I think, in hindsight, I would have had a second surgeon scrubbed in surgery,” Mr Lal said.
“In hindsight” he also agreed he would have “immediately called in” help.
“I will do it” in the future, he added.
He also agreed the surgery was recorded, for a training video, and that, even though Ms Sheedy was “anonymised” in the recording, he had not sought her consent to record the surgery.
He agreed he did not consult with Mr Kavanagh about the case, but he would do this in the future.
He also agreed, in hindsight, he would have approached the surgery differently, and he would have involved a second surgeon.
“I can’t recall repeatedly refusing help,” he told Ms Power.
Interim Chief Clinical Director, Dr Gerry Burke broke down as he explained to the Sheedy family he was sorry for what had happened and that the hospital group had drawn up 25 recommendations aimed at learning lessons, and preventing similar tragedies occurring.
A statement of apology, read out on behalf of UL Hospitals Group acting chief executive, Noreen Spillane, expressed her “deepest sympathies to Jessica’s family”.
“Patients and their families put their trust in hospitals and in healthcare professionals and on this occasion we have fallen far short of the standards of care expected.”
Coroner John McNamara said he accepted both, the evidence of Mr Lall, as well as the theatre staff who had assisted him.
Recording a verdict of medical misadventure, he said there had been “missed opportunities” in Ms Sheedy’s care.