Ireland's longest-running medical inquest finishes with verdict of medical misadventure
Members of Shane Banks's family — his wife Ciara flanked by his parents Margaret and Mickey, and his brothers Allen and Ray — after the medical inquest into his death in University Hospital Galway in 2019. Picture: Hany Marzouk
Questions remain for the widow and three children of Shane Banks, whose inquest is thought to be the longest medical inquest in Irish history.
A verdict of medical misadventure was returned into the death of Shane Banks (43) at University Hospital Galway (UHG) in June 2019, following two operations he underwent for lung cancer.
Speaking afterward, his widow Ciara Banks (née McDermott) said questions remain for her and her three children about Shane's death. She called on the HSE and Saolta hospital group to act on the coroner’s recommendations.
“It is too late for Shane and our children,” she said, adding: “We can try to ensure it doesn’t happen to any other family. We hope the same situation Shane found himself in does not arise ever again.”
The inquest opened on January 4 and was described as the longest-running medical inquest in Ireland.
Coroner Ciarán MacLoughlin made three recommendations, including that a mentorship programme be established for doctors under the Irish Medical Council, the professional training colleges, and the HSE.
He recommended standard operating procedures for all cancer multi-disciplinary teams be communicated to all hospitals, and arrangements for consultant leave be standardised to prevent situations arising where doctors go on leave soon after critical procedures.
The inquest heard the cardiothoracic surgeon involved, Professor Mark DaCosta, was under mentorship and supervision for his cardiac practice at the time, but not for thoracic work and lung procedures.
The Banks family was not made aware of this until after his death, the court heard.
“With hindsight, having learned from these events, the hospital accepts that there was a failure to adequately consider the introduction of similar supports for Prof Da Costa’s thoracic practice and with similar mentorship and supervision of his thoracic practice,” barrister for the Saolta group Luán Ó Braonáin SC said:
A hospital spokeswoman said in addition to accepting the recommendations they will do “a more formal review of ICU care” despite high standards.
The court heard from witnesses that although Mr Banks had lung cancer, he did not die of cancer. He had been diagnosed after tests in March having coughed blood and been unable to shake a chest infection.
Evidence was given that he was admitted to UHG for an operation planned for June 7 under Prof DaCosta, this elective surgery was delayed until June 10.
The lobectomy was performed involving removal of two lobes from his right lung. Mr Banks was in ICU for three days, and treated for pneumonia. However, the tumour was found to be “significantly invasive”, the court heard and a second procedure was planned following discussion with a multi-disciplinary team.
This took place on June 21 which was the Banks’ sixth wedding anniversary. Mrs Banks gave evidence that her husband gave her an anniversary card before surgery that afternoon.
During this procedure, the inquest heard the right main pulmonary artery was torn, and blood loss of 2.2 litres was recorded. Prof DaCosta gave evidence that he described this as “a surgeon’s nightmare” during the procedure.
Two surgeons were called to assist. After the bleeding was stopped, Mr Bank’s right lung was removed. He was brought to ICU after 1am and temporarily put on a ventilator.
Prof DaCosta remained at the hospital until about 6.30am, then departed on leave. He disputed evidence from other surgeons he had not alerted them to his plans.
On Friday, solicitor for the family, Roger Murray of Callan Tansey said Mr Banks “fought courageously” through the next few days, and that “he ran the race of his life”.
In the early hours of June 24, his condition was seen to deteriorate and he was given emergency treatment but pronounced dead at 9.18am.
Mrs Banks was at the hospital, but did not enter his room, which she told the inquest has left her “tortured with regret”. Conflicting evidence was heard around what the family were told at the time.
Mr Murray said they were robbed of the cultural activities surrounding death and said: “Shane Banks was robbed of that time.” He said a medal for the Warrior’s Run in Sligo which Mr Banks had planned to compete in now hangs instead on his gravestone.
The cause of death was given as acute respiratory failure due to pulmonary oedema and damage in the remaining left lung, following removal of the right lung three days earlier.
The inquest heard Prof DaCosta, who was removed from surgical work in July 2019, had worked at UHG since 2005, having trained with the Royal College of Surgeons in Ireland, and had worked in Dublin, Scotland, England, America, and his native Singapore.
Johan Verbruggen, solicitor with law firm Callan Tansey said on Friday after the verdict was delivered: “The family and the legal representative would like to thank the coroner for his lengthy and thorough inquiry, no stone was left unturned in finding out how Shane died.
"It is over to the hospital now to take the lessons and recommendations from the inquest, and use them to improve patient safety.”
