Partner of brain bleed victim fears patients are still at risk
Gwen Bradley, who withdrew co-operation from the second day of the inquest at Cork City Coroner’s Court into the death of Evan Morrissey, expressed bitter disappointment with the outcome after a jury returned a narrative verdict.
The 28-year-old father-of-five from near Clonmel in Co Tipperary died in Cork University Hospital (CUH) on March 22, 2014, just days after his fourth presentation at South Tipperary General Hospital between March 2 and March 18 where he complained of severe headaches, vomiting, neck pain and photophobia.
He was sent home from hospital after the first three visits when doctors diagnosed migraine. But his symptoms continued, and worsened, until a brain scan on March 18 revealed an acute bleed in his brain.
He was transferred to CUH that night where he suffered cardiac arrest at 1.30am, and underwent emergency brain surgery. He never regained consciousness and was pronounced dead on March 22.
Consultant neurosurgeon at CUH, Mr George Karr, said the cause of death was haemorrhage due to the rupture of an aneurysm in the right middle cerebral artery.
The jury’s verdict said Mr Morrissey died in CUH following his transfer from South Tipperary General Hospital, and it outlined the cause of death. But it made no reference to his four presentations at the Clonmel hospital.
Ms Bradley said the inquest has given her no closure, and she fears the system still exposes headache patients to risk.
“If they’re just going to brush it under the carpet then how are they going to fix it? They’re not even willing to answer questions about it, or let questions be asked. So how are you supposed to fix something when won’t even look at the problem,” she said.
Her solicitor, Cian O’Carroll, described it as a poor outcome for the system of inquests in Ireland.
He said a strong limitation placed on questions that could be asked at the inquest meant there would be a limited outcome.
“We made every effort we could to ask questions of the doctors,” he said.
“We asked from the outset for an independent doctor to be allowed give evidence. That was refused, and ultimately an important line of questioning was blocked, and my client felt she couldn’t continue involvement or co-operation with the inquest.”
The inquest was told by South Tipperary General’s clinical director, Dr Aamir Majeed, that protocols have been introduced since December to identify red-flag issues among patients presenting with headache.
But Mr Carroll said they are the old protocols which have just been extended to other areas of the hospital — which does nothing to improve patient safety.
Earlier, consultant radiologist at the Clonmel hospital, Dr John Hynes, told coroner, Philip Comyn, that a non-contrast CT brain scan performed on Mr Morrissey on March 6 — his second presentation at the hospital — was clear.
Mr Morrissey presented at the hospital for the fourth time that month on March 18 with the same symptoms.
Dr Raman Chaudhary, the medical senior house officer on duty in the emergency department, said he considered several differential diagnoses, including meningitis and intra cranial haemorrhage, and ordered a CT scan.
Dr Hynes said when he saw a request for another CT scan on the same patient with the same symptoms just a few days after a scan came back clear, he felt a lumbar puncture was a better option.
“My fear was that if you are querying meningitis, do the lumbar puncture now. If a patient has meningitis, you don’t waste time in administering antibiotics because hours and minutes matter. In my opinion, a lumbar puncture was the relevant investigation,” he said.
Following a discussion with Dr Chaudhary, Dr Hynes cancelled the scan request at 3.37pm but when Dr Said Hassan, the medical registrar on-call, visited Dr Hynes in his office and outlined the case, at CT scan was arranged for 4.44pm, and Dr Hynes identified an “acute and devastating” intra cranial haemorrhage.
He told the inquest that it had occurred within the previous two days, at most.
Dr Christina Donnellan, the consultant physician at South Tipperary General, said Mr Morrissey was alert and stable when he left in an ambulance for transfer to CUH at 7.40pm. Mr Karr said he was stable and alert when he arrived at CUH at 10.30pm and they planned to conduct investigations the following morning, but that he suffered a sudden cardiac arrest at 1.30am.
“I regret that we were unable to help. While urgent investigation and treatment was planned for the next morning, we did not get a chance to implement these,” Mr Karr said.
Mr Comyn praised Mr Morrissey’s partner and family for consenting to organ donation which transformed the lives of five people.
