Inquest into Limerick woman's death hears of 'missed opportunities' in her care

A verdict of medical misadventure was returned in the inquest into the death of Eve Cleary
Inquest into Limerick woman's death hears of 'missed opportunities' in her care

Melanie Sheehan Cleary and Barry Cleary, holding a framed photograph of their daughter, Eve Cleary, outside Limerick Coroners Court.

A coroner has made a recommendation that HSE guidelines around assessing patients for risk of blood clots, particularly deep vein thrombosis, be followed by staff at University Hospital Limerick (UHL) “as much as they can” after a young woman died from blood clots in her lungs just hours after she was discharged from the hospital.

Eve Cleary, 21, from Corbally, Limerick, died in the early hours of July 21, 2019, after presenting at UHL while suffering cardiac arrest and with a swollen leg, the inquest held at Limerick Coroner’s Court heard.

Ms Cleary initially presented at UHL two days previously, July 19, with a swollen right leg after she had suffered a fall in Limerick City.

She spent 17 hours on a trolley in the hospital’s emergency department (ED) with only a hoodie for a blanket.

Her trolley was one of dozens more cramped together in a corridor of the ED, where, on the day, a “record” number of patients were waiting for beds, the inquest heard.

Ms Cleary’s parents said that when they visited their daughter in the hospital they found her on a trolley near a sink that had been used as a toilet.

Her heartbroken mother Melanie Sheehan Cleary said “the smell of urine caught in your breath and made you cough”.

Ms Cleary had presented at the hospital on July 19 with a number of risk factors for thrombosis and blood clots, including being on a contraceptive pill that specifically increased the risk of blood clotting. She was a smoker, was overweight, and there was a history of blood clots in her family.

She spent the night on the trolley in the overcrowded ED and was given a bed on a ward the following day, July 20.

Her patient files appeared to be missing on the ward, and the ward nurses were not fully aware of why she was there, the inquest heard.

The hospital was operating with a skeletal staff and, as it was the weekend, and there was no staff to operate the hospital’s ultra-sound equipment. 

At this point, Ms Cleary’s mother temporarily left the inquest in tears saying, “So, she would have died anyway ... disgrace”.

A blood test and an ultrasound scan are the two main methods of diagnosing a blood clot, the inquest heard.

Ms Cleary was not assessed for risk of blood clots and she was never seen by a consultant, although a report of a CT scan of her leg, which found no fracture or abnormalities, was read by the hospital’s on-call consultant orthopedic doctor.

Ms Cleary was discharged with a suspected soft tissue fracture.

Her mother wept as she recalled how her daughter’s leg had swollen to “three-and-a-half times” its normal size while in the hospital, and that it turned dark red “like the colour of a Christmas ham”.

A WhatsApp message found on Ms Cleary’s phone, which she had sent to a work colleague, indicated that she believed those involved in her care were considering she may have had a blood clot, however, the inquest heard that at no stage did any of the doctors involved in Ms Cleary’s care ever suspect at any stage that she was suffering from a clot.

Four hours after she was discharged from UHL, on a wheelchair, as she could not walk with the pain, Ms Cleary went into cardiac arrest at her family home.

Her father, Barry Cleary, fought back tears as he described how he desperately tried to keep his daughter alive by performing chest compressions and CPR on her.

She was rushed by ambulance to UHL where she was pronounced dead at 1.50am, on July 21.

A post mortem found the cause of death was due to cardiac arrest due to extensive bilateral thrombo-embolisation or clots that had blocked her lungs.

The clots were most likely due to recent trauma, stated UHL pathologist, Dr Teresa Laszlo, who conducted the autopsy, but she could not say when exactly the clots had occurred.

Counsel for the Cleary family, Doireann O’Mahony, said it was “insulting” to Ms Cleary’s family that no formal apology had been offered to them surrounding her death.

Ms Cleary’s parents said afterwards that their daughter’s death could have been prevented and that she had been “failed” by those tasked with her care.

Barry Cleary likened the ED to a “cattle mart” due to the high number of patients on trolleys when his daughter was there.

Coroner John McNamara returned a verdict of medical misadventure.

He said there were “missed opportunities” in Ms Cleary’s case, however, she stressed this was not to fault anyone involved in her care.

Mr McNamara said he also accepted Ms Cleary’s parents’ “harrowing evidence” about what they had witnessed in the overcrowded ED.

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