'Our lives will never be the same': Hospital failed to diagnose talented footballer's meningitis infection
Medics at Mayo University Hospital in Castlebar failed to diagnose Adam Mulchrone's infection when he was referred to the hospital on January 26, 2019, and he was discharged.
A verdict of medical misadventure has been recorded at an inquest into the death of a talented young footballer.
Mayo University Hospital (MUH) did not oppose the verdict in the case of 21-year-old Adam Mulchrone, from Sandyhill in Westport, who died on January 17, 2019.
The hospital subsequently issued an “unreserved apology” to his family for the failures in care that led to the young man’s death.
The Westport United player and Sligo IT student suffered multi-organ failure as a result of meningococcus septicemia due to meningitis infection.
The inquest into his death took place over two days at Swinford Courthouse last week.
The inquest heard that death of this type of infection is exceptionally rare with consultant pathologist at MUH, Dr Tamas Nemeth, stating that he has only seen two cases in his 25-year career in the county.
Medics at MUH failed to diagnose Adam’s infection when he was referred to the hospital on January 26, 2019, and he was discharged.
His condition deteriorated when he returned home and his family brought him back to the hospital in the early hours of January 27.
Adam was placed in intensive care but his condition failed to improve and he was pronounced dead at 4.42pm later that day.
The inquest heard that on the morning of January 26, Adam left his family home to attend football training but returned early as he was not feeling well; he had a headache, a temperature, and was vomiting.
His mother Mary called Westdoc to arrange a GP appointment.
The Westdoc doctor on call believed Adam had a meningitis-related infection and recommended that his family take him to the Emergency Department at MUH.
In her statement to the inquest, Mary Mulchrone said Adam was seen at approximately 5pm by a doctor, who she now knows is Dr Georgios Diakidis.
Her son told the doctor he had “the worst headache he had had in his life”.
His mother and sister saw red flares/patches on Adam’s skin in the neck and chest area; Ms Mulchrone said they pointed these out to Dr Diakidis but he indicated they were not concerning.
Ms Mulchrone said Adam told the doctor his neck and jaw were sore but after a brief examination, the medic said he had no concerns. She said her son also mentioned the red patches to Dr Diakidis.
Adam was discharged at approximately 7.15pm with a prescription for what she believed to be Ibuprofen, paracetamol, and stemetic.
Ms Mulchone said the loss of Adam has been unimaginable for the family and the hours spent in the hospital that weekend will haunt them forever.
“The 27th day of January 2019 our world changed forever. We lost our beautiful and kind son and brother, Adam. Our lives will never be the same again,” said Ms Mulchone. “There is a hole in our hearts that will never be filled.
“Any moment of happiness we have still feels heavy and wrong because Adam isn’t here to share it with us,” she added.
Dr Diakidis, who at the time was an Emergency Department Registrar at MUH, was unable to attend the inquest due to illness to a family member. His statement was read out in the coroner’s court.
At odds with Ms Mulchrone’s statement, Dr Diakidis said his examination of Adam revealed no rash or neck stiffness. Adam told him he had a headache which he rated as seven out of 10 in terms of pain.
The doctor said the examination was “unremarkable” and he carried out a full neurological examination to consider the potential diagnosis of meningitis/meningococcal septicemia.
"The neurological examination was unremarkable with no signs of meningism or rash.”
The doctor directed a series of investigations including bloods, urine, and a chest X-ray; he said Adam’s blood results were not consistent with significant infection.
He re-assessed Adam at 7pm and the 21-year stated he had improved and was feeling fine.
“I specifically asked Adam if he had any neck stiffness and he stated he did not have. I remember that he started moving his head up and down, from right to left but his neck was not painful.”
He said his “clinical impression” was that Adam had a viral illness such as gastroenteritis or influenza.
Conor Halpin SC, representing MUH, said the hospital accepts that Adam’s vital signs should have been re-assessed before he was discharged.
Under cross-examination from Ciaran Tansey, representing the Mulchrone family, Dr Jason Horan, Consultant in Emergency Medicine at MUH, said what happened to Adam “highlighted a deficiency in our processes”.
“A second set of vital signs should have been done,” said Dr Horan. “This case does highlight how important getting a second set of vitals is.”
The hospital has implemented a number of changes to how it operates following Adam’s death.
As well as ensuring the second set of vitals are taken as a matter of course, the hospital has increased the frequency of “nursing huddles”, which see nurses check in with the shift manager.
A patient tracking system has been introduced and an electronic handbook has been implemented for staff. The handbook included guidelines relating to meningitis.
When asked by Mr Tansey what life-saving actions are taken when a patient has meningococcus septicemia, Dr Horan said intravenous antibiotics, intravenous fluids, and other agents are used to treat patients.
Dr Horan accepted that Adam did not receive these treatments when seen by Dr Diakidis.
MUH’s legal representatives offered no opposition when Mr Tansey sought a verdict of medical misadventure.
Coroner Pat O’Connor recorded a verdict of death by medical misadventure.
“I do hope and pray that lessons are learned from Adam’s passing,” said Mr O’Connor.
Mr Halpin then read a letter from MUH general manager, Catherine Donohoe, in which the hospital apologised for the “failings in the standard of care provided to Adam”.
- Western People
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