The family of a woman who never woke up from routine surgery has urged medics at Cork University Hospital (CUH) to review protocols on the management and monitoring of patients undergoing disc removal surgery.
Patricia Kelly's family said they hope that lessons will be learned after an inquest into her death returned an open verdict today.
Ms Kelly, 45, a married mother-of-one from Castletreasure, Douglas in Cork City, underwent disc surgery in CUH on February 11, 2014, but never regained consciousness. She died in the hospital on December 17, 2015 after 22 months in a coma.
Cork City Coroner, Philip Comyn, told the inquest jury yesterday that it was open to them to issue recommendations.
He suggested they consider recommending that a multi-disciplinary team at CUH review the hospital's protocols about there being no need for patients with a history of hypertension to discontinue taking ACE inhibitors - medications used to treat high blood pressure- before surgery.
Medical views differ from hospital to hospital on this protocol, the inquest had heard.
He also suggested they consider recommending that CUH review its use of intra-arterial monitors for all anterior and posterior cervical discectomy - disc removal - procedures.
While the jury chose not to issue recommendations, Mr Comyn said he hoped CUH might "consider carefully" the issues identified during the inquest.
Speaking afterwards, Ms Kelly's husband, John, said they hope lessons are learned.
From the first day, what we wanted was to know why did it happen, it shouldn't have happened, and hopefully it will never happen again to some other family - the pain and suffering that we went through.
"Hopefully it will never happen to another family like it did to us."
His niece, Michelle Sullivan, said while facts emerged, several questions still haven't been answered.
The inquest was told that Ms Kelly, who was diabetic and had a history of hypertension, pulled two discs in a simple fall in November 2013 and was advised that she would need surgery urgently.
John dropped her to CUH early on February 11, 2014, for the day-case procedure, which went well, but she never woke up following surgery.
Her family was given no explanation as to why.
Two reviews, one internal and one external, were conducted and no recommendations arose.
But Donncha O'Brien, a consultant neurosurgeon at Beaumont Hospital, who reviewed the case for the coroner, yesterday criticised the internal hospital inquiry.
He said given her medical history and her raised BMI of 42, he would not have proceeded with surgery without input from cardiology experts.
He pointed to the monitoring of her blood pressure with a cuff on the finger, rather than an intra-arterial line which would have picked up problems sooner.
He also raised concerns about how she wasn't told to stop taking her blood pressure medication, Ramipril, before the surgery, medication he said would have exaggerated the impact of the anaesthetic.
And while doctors at CUH were of the view that it wouldn't pose a problem, Mr O'Brien said if that's the view, you have to be well armed to deal with it.
The coroner said that view on the medication seems to vary from hospital to hospital. Mr O'Brien said Ms Kelly's death seems to be an unfortunate consequence of that.
Dr Osman Ahmed, the senior anaesthetist registrar on the day, and who was under the supervision of Dr Brian O'Donnell, said following a pre-op assessment, Ms Kelly was not deemed a candidate for an intra-arterial monitor.
He said the medical team planned for a "very standard, straightforward and ordinary anaesthetic management" and the surgery was routine.
It was very unexpected that this patient did not wake up. It was quite distressful to me, the team and I would like to express my sympathies and condolences to the family," he said.
Assistant state pathologist, Dr Margot Bolster, described it as a "most complex case".
She said there was no evidence of neurodegenerative disease and the cause of death was prolonged coma due to severe hypoxic brain injury during surgery, complicated by bronchial pneumonia.
Mr Comyn said while the surgery is described by some as routine, it is complex and carries risks. He said the tragedy had taken its toll on Ms Kelly's family, but he also appreciated the effect it has had on CUH's medical staff.