Hospital failed to explain why post mortem was necessary
Cork’s city coroner, Dr Myra Cullinane, said Cork University Hospital (CUH) had failed to properly inform the family of William (Bill) Shannon, 79, of the need for a post mortem following his death from the “health-care-acquired” infection last October.
It is important that such deaths are properly reported and investigated, Dr Cullinane said.
But Mr Shannon’s sister, Elizabeth, told the inquest that a nurse had told her there would be no need for a post mortem.
She said she was shocked to learn afterwards that a post mortem had been carried out.
Dr Cullinane said this had caused distress to the family.
Despite the recommendations of reports like the 2000 Coroners’ Practice and Procedures, and the 2006 Madden Report, that hospitals appoint a person to liaise with families and keep them informed of post mortem practices, Dr Cullinane said this had not occurred here.
“The appointment of such a person would avoid such distress as patently occurred in this case,” she said.
William Shannon, from Grove House, Passage West in Cork, died at CUH on October 4, 2006.
The inquest heard how he had attended the South Infirmary Hospital last April with severe heart failure.
Tests showed that he was “colonised” with MRSA but that there was no infection and he was treated successfully.
More tests showed that he had an advanced skin cancer tumour on his scalp.
But a decision was taken to postpone the removal of the tumour until after he had an operation to replace a heart valve. He underwent major heart surgery in CUH last May and made a full recovery.
He returned to the South Infirmary last September to have the tumour removed in a simple 20-minute procedure carried out by consultant plastic surgeon, Dr Sean O’Sullivan.
Dr O’Sullivan told the inquest that he was aware Mr Shannon had had MRSA but there was no evidence of active infection ahead of the cancer surgery.
Nevertheless, he took the decision to place Mr Shannon last on his list of operations for September 25 to minimise the risk of spreading the bug.
Afterwards, the wound site was treated fully with an antiseptic which kills all bacteria, including MRSA, Dr O’Sullivan said.
Mr Shannon was discharged later that day but became unwell in the following days.
He was back at the South Infirmary on October 1 with a massive infection and renal failure. He was transferred to CUH the next day but despite intensive treatment, he died on October 4.
Assistant State pathologist Dr Margaret Bolster said the cause of death was infection of the surgical wound on his head due to MRSA, on a background of other health problems, including heart disease.
But Mr Shannon would not have died at this time if he had not contracted MRSA, she said.
Dr Cullinane returned a verdict of death due to health care acquired infection.
Ms Shannon, who was visibly upset throughout the inquest, declined to comment afterwards.
Asim Sheikh BL, representing CUM and the South Infirmary, admitted there had been a breakdown in communications between CUH and the family and he apologised for the distress caused.
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