Public and private hospitals must share all patient information, recommends coroner

Inquest hears woman died not knowing she had been diagnosed with 'potentially life-threatening illness'

Sisters Martina and Breda O’Loughlin photographed outside the coroners court in Limerick where their mother Brigid’s case is being held. Picture: Liam Burke/Press 22

A coroner’s court having heard claims that a mother of two died not knowing she had been diagnosed with a “potentially life threatening illness”, has recommended “in the interest of public health and safety”, that both public and private hospitals share and document all of a patient’s medical information.

Brigid O’Loughlin, 78, from Ennis, Co Clare, died at University Hospital Limerick (UHL) on October 4, 2017.

Ms O’Loughlin had previously been referred by her GP, a number of times, to attend at both UHL and at Bon Secours Hospital, Galway, after she complained of chronic abdominal pain, vomiting, and nausea over several months.

After undergoing a cat scan at the Bons, Galway, on July 24, 2017, Ms O’Loughlin was diagnosed with Mesenteric ischemia, a potentially fatal condition, occurring when blocked or narrowed arteries restrict blood flow to the small intestine.

It was agreed by all parties that Ms O’Loghlin’s discharge notes from the Bons, Galway on August 4, had not made any reference to the serious illness diagnosis, and that this should not have happened.

The late Brigid O’Loughlin. Picture supplied by family and sent by Press 22

Ms O’Loughlin, suffering continued symptoms, was subsequently admitted to UHL on August 12, but she was discharged 12 hours later.

She was readmitted to UHL a few days later, and underwent surgery to her small bowel, after senior clinician, Dr Mike Bourke, determined she was “critically ill and required major surgery”.

The deceased’s daughter Martina O’Loughlin disputed evidence given by Dr Deirdre Mullane, a consultant at the Bons Galway, that Dr Mullane had in fact informed the patient and family members of the diagnosis prior to the patient being discharged on August 4.

The court heard there were no notes of the alleged conversations between the Bons and the family.

Dr Mullane said she sent Ms O’Loughlin’s discharge summary to her GP, Dr John McCarthy on August 14.

Dr McCarthy said he received this on August 16, but that the report noted that “no surgical intervention” was needed, after Ms O’Loughlin’s condition in the Bon Secours had improved prior to her being discharged.

Dr McCarthy said he could not confirm if he had sent this information to UHL but that he believed if he received it he would have sent it.

UHL has found no record of the discharge summary, it was heard.

Several doctors involved in Ms O’Loughlin’s treatment at UHL said they had not been aware of the initial diagnosis from Bon Secours, Galway.

UHL sent a letter of unreserved apology to Martina O’Loughlin in October 2019 regarding her mother’s care at the Limerick hospital.

The letter stated that, although Ms O’Loughlin’s condition was grave, there was the possibility she could have survived had the diagnosis been made earlier and appropriate treatment followed.

A postmortem found the cause of death was bronchial pneumonia following emergency surgery linked to Mesenteric ischemia and other contributory medical factors.

Limerick City coroner, John McNamara, said the appropriate verdict was “a narrative” one, involving the patient’s “complicated” medical history, as well as a diagnosis of a “potentially life threatening condition” being “omitted” from discharge notes.

Mr McNamara recommended that patients medical information “should be clearly documented on the (hospital’s) discharge summary”, and that both private and public hospitals should “share, all scans and medical records, which should be made available electronically or otherwise, both in the interests of the public safety and hospital staff”.

He further recommended “all patient medical notes should be clearly and eligibly signed and dated”.

He described Ms O’Loughlin’s two daughters, Martina, and Breda, as “great advocates for their mother”, and that, as both were also recently grieving their father’s death, they had both “suffered terrible loss”.