Young mother bled to death following 'systems failure' in UHL

Coroner recorded a verdict of medical misadventure but said there was no evidence of wrongdoing by anyone involved in Susan Doherty’s care

Susan Doherty's grieving husband Roland said: '[The HSE] need to change their systems to ensure this doesn't happen again. I don't want anyone else to go through what I have been through for the last two years.' Picture: Brendan Gleeson

A young mother bled to death following a “systems failure” in her care while she was an inpatient at University Hospital Limerick (UHL), an inquest has heard.

The UL Hospitals Group has issued an unreserved apology to the family of Susan Doherty, 47, who died in UHL on July 4, 2020, eight days after she presented with a low white blood cell count, sore throat, and high temperature.

Doctors requested an “urgent” scan of Ms Doherty’s abdomen and pelvis after she complained of severe pain in her chest, but this was not followed up on, and she died after suffering a massive bleed to her spleen.

By the time she received the urgent CT scan, nearly 24 hours later, she had suffered a cardiac arrest.

Conor Halpin, counsel for the UL Hospitals Group, expressed his “deepest sympathies to Susan’s family” and read out a letter of unreserved apology which was signed by Noreen Spillane, chief operations officer, UL Hospitals Group.

Eleven recommendations were made following an internal review by the hospital group but these have yet to be implemented.

Mary McKiernan, a senior nurse manager, who has since retired, said Ms Doherty was not monitored as per the hospital’s protocols and that the patient’s ward was short-staffed.

Ms McKiernan said she had “pushed” for Ms Doherty to receive an urgent CCT scan but this did not happen.

Members of the late Susan Doherty's family — her husband, Roland Doherty, her mother, Shelia Moloney, and her brother Rob Moloney, at Limerick Coroners Court on Monday.

The inquest heard that, prior to being admitted to UHL, Ms Doherty had regularly been receiving the therapeutic drug, GCSF, for neutropenia, which carries an extremely rare risk of splenic rupture.

After she was admitted to the hospital she received the drug heparin which is used in the treatment of blood clots which may have exacerbated her internal bleeding.

Coroner John McNamara said it appeared there was a conflict between clinicians working on the frontline of the hospital and that there were capacity and access issues “at the heart” of Ms Doherty’s death.

He said that, if a CT scan had been performed on her earlier: 

[I]t would have without any shadow of a doubt changed the trajectory of Susan’s treatment and eradicated doctors' concerns [about a lung blood clot].

Mr McNamara said it appeared that without a CT scan doctors were “fighting with one hand tied behind their backs”.

He said an autopsy concluded that the cause of death was due to “shock intra-abdominal hemorrhage, due to splenic rupture” and, there was no evidence of any wrongdoing by any members of Ms Doherty’s care team.

Intensive care consultant at UHL, Catherine Nix, told the inquest that doctors in the US were using handheld bedside scans to fast-track diagnosis in their patients and that this technology should be used more often in UHL and other Irish hospitals.

Mr McNamara recorded a verdict of medical misadventure, but said there was no evidence of any wrongdoing by anyone involved in Ms Doherty’s care.

He recommended the HSE and the UL Hospitals Group consider increased use of handheld scanning devices.

Ms Doherty’s husband, Roland Doherty said: “It’s not going to bring Susan back, but the HSE accepted there were major failings.

“They need to change their systems to ensure this doesn't happen again, I don't want anyone else to go through what I have been through for the last two years.” 

Paying tribute to his late wife, he said: 

She always had a smile on her face no matter what, and she adored the ground our beautiful daughter Charlotte Rose [now aged 5] walked on, but she only had two years with her.