Melissa Barry was speaking after the Dublin coroner returned a verdict of medical misadventure at the inquest into the death of Susan McGee, aged 52, from Skerries Rd, Rush, Co Dublin.
The mother of two died at Beaumont Hospital on July 24, 2013, having developed a rare C.diff (clostridium difficile) infection after a hernia operation at The Hermitage Medical Clinic 11 days earlier.
The inquest heard from consultant surgeon Professor Arnold Hill that during the hernia operation a superficial outer colon tear was repaired and Mrs McGee was placed on a longer course of antibiotics. One of the risk factors for developing C.diff infection is antibiotics.
Returning the verdict, coroner Brian Farrell said C.diff normally causes diarrhoea but, in this case, it resulted in an “extremely rare” severe enterocolitis – inflammation of the digestive tract. She went into multi-organ failure after developing sepsis, secondary to the enterocolitis caused by the C.diff infection.
The family’s legal team had concerns about the handover of Mrs McGee’s care when Prof Hill went on leave three days after her readmission to The Hermitage with a small bowel obstruction. He said he anticipated a “prompt” recovery when he handed care from Saturday, July 20, to consultant general surgeon Colm Power. However, Mr Power was not aware that surgical registrar Firas Ayoub could only review Mrs McGee on Saturday.
Mr Power left instructions he should be called if there was any deterioration in Mrs McGee’s condition.
When her blood pressure dropped on Sunday evening and “brown faecal matter” came up her nasal gastric tube, the resident medical officer on call was called instead. He consulted with Dr Ayoub rather than Mr Power. She was first seen by Mr Power the following morning after he was told of her overnight deterioration.
Summing up, Dr Farrell said the reporting structures after handover were unclear to some nurses “and even the consultants”.
Counsel representing The Hermitage, Conor Halpin said it is “quite clear that it was set out in the medical notes” who was to be contacted and had responsibility. The Hermitage has since expanded on its handover protocol, he said.
Following the verdict, the family’s solicitor, Dermot McNamara, said the case “highlights the need for a fail-safe handover protocol between consultants, in both the private and public sector”.