Tipperary farmer died after brain bleed was missed in scan read remotely and out of hours

Family hit out at long legal battle with HSE: 'It was extended out and it prolonged our grief, compounded our loss as we were dragged through the courts'

Carmel O’Connor with her children James and Katherine Kirby outside the Four Courts after they settled an action over the death of PJ O’Connor, 71. Picture: Collins Courts

The HSE outsourced radiological reporting at University Hospital Limerick and a man’s CT brain scan was read remotely in the early hours — but a brain bleed was missed, the High Court has heard.

When the condition of the 71-year-old Tipperary farmer, PJ O’Connor, deteriorated and he needed to be transferred to another hospital for treatment, he had to wait four hours for an ambulance.

After finally being transferred, Mr O’Connor was treated in ICU but died nine days later on December 6, 2021.

In February, the HSE admitted a breach of duty in the failure of its radiology services to detect the brain bleed and the consequent provision of contra indicated treatment. 

It further admitted a breach in the provision of timely onward ambulance transportation to a Cork hospital for neurosurgery and delay in providing appropriate reversal treatment to Mr O’Connor, which it admitted caused his wrongful and untimely death.

In a letter of apology to the O’Connor family, the HSE and the hospital said “it is with regret” that the care provided to Mr O'Connor, from Capparoe, Nenagh, at UHL on November 27, 2021 “fell below our standards and best practice".

It continued: “We acknowledge that these failings led to the untimely death of Mr O’Connor. 

"We extend our sincere apologies to both you and your family for the distress and upset that this has caused, and we do not underestimate the heartbreak and upset caused by the death of a much-loved member of your family,” read the letter,  signed by Ian Carter, chief executive of HSE Mid West Acute and Older People Services.

The letter was read out in court on Thursday as Mr O’Connor’s family settled a High Court action over his death.

Outside the Four Courts, Mr O'Connor's son James said it was a long legal battle.

“It was extended out and it prolonged our grief, compounded our loss as we were dragged through the courts.” 

His sister Katherine Kirby said they had taken the case to highlight the failings in the health services “so another family does not have to go through this".

“It is important for us to acknowledge how much we miss my father and Carmel’s husband and the substandard care he received that means he is not here with us today."

The family’s counsel, Patrick Treacy, instructed by Cian O’Carroll solicitors, told the court the events have had an “enormous traumatic effect” on Mr O’Connor's wife Carmel and their four children. 

On November 26, 2021, he said Mr O’Connor was admitted to UHL with right facial droop; an acute stroke was diagnosed and a CT scan of his brain was taken. 

Mr Treacy told the court the scan was read remotely, out of hours, by a radiologist as the HSE had outsourced radiological reporting to a company.

Counsel said the radiologist got the scan after 2am and  reported back at 2.30am. Mr Treacy said a possible explanation was offered by the reporting radiologist that Mr O’Connor’s brain was assessed in the brain soft tissue window and may not have been assessed in the head bleed window. 

The radiologist said it is possible he did not do the head bleed step and was not sure if it was related to the time at night or because he was distracted by the appearance of the vertebral arteries.

Counsel said the brain bleed was missed and Mr O’Connor was started on emergency treatment to dissolve blood clots and to restore blood flow. His condition deteriorated and it was decided to transfer him to a Cork hospital. 

However, Mr Treacy said there was an “inordinate delay” and an ambulance, which was booked at 11.30am, did not arrive until 3.30pm.

A call review report relating to the ambulance transfer noted significant challenges with emergency ambulance availability due to service-level demand and hospital delays.

Noting the settlement and approving the division of the €35,000 statutory mental distress payment, Mr Justice Paul Coffey said it was a very sad and tragic case and he extended his deepest sympathy to the O’Connor family.