Thomas Brennan, aged 79, of Green Trees Road, Terenure, Dublin 6, was rushed to Tallaght Hospital by ambulance on July 21 after collapsing in his bathroom. He arrived at the hospital at 12.30pm.
His main complaint was of severe abdominal pain and he was diagnosed with an inflamed gall bladder.
A diagnosis had not been finalised, however, and he was referred for a medical review at 8pm with regard to other symptoms, including fluid around the heart.
Mr Brennan was on a trolley in the resuscitation room of the emergency department and had still not been reviewed by the medical team or admitted when he suffered a sudden collapse at 1am on July 22.
He was pronounced dead almost an hour later, Dublin County Coroner’s Court heard.
Coroner Dr Kieran Geraghty said “it did not seem right” that Mr Brennan had been prioritised by the emergency department as a serious case, yet had not been seen by the medical team five hours later.
Acting chief executive John O’Connell said Mr Brennan “could not have been in a better or safer place”, but accepted that if it was his family he would not want anybody waiting any period of time.
The coroner also expressed alarm that one doctor who reviewed Mr Brennan, specialist registrar in emergency medicine David Menzis, was working a 36-hour shift.
“Anybody having to work for 36 hours without sleep would be at risk,” he said.
The coroner asked Mr O’Connell to take action on the matter and to also take action with regard to a practice where some doctors do not read the patient’s notes, but rely on a handover from other doctors.
A postmortem found Mr Brennan’s death was due to a heart attack which had occurred three days earlier.
Dr Menzis told the inquest he did not feel a heart attack was likely, but he did not rule it out.
Consultant in A&E medicine Dr Jean O’Sullivan said there was no evidence of a heart attack on two ECGs carried out.
The coroner recorded a verdict of death by natural causes and he accepted there had been no evidence that any treatment given would have changed the outcome.