Death of mother of four at St Vincent’s Hospital due to medical misadventure, inquest finds

A verdict of medical misadventure was recorded at an inquest into the death of a 49-year-old mother of four from Ballina, Co Mayo, who died in St Vincent’s hospital, Dublin, eight days after she had an elective operation for the removal of her pancreas, gall bladder and spleen.
The inquest heard that, on the day she died, “obviously abnormal” results from a blood test were not immediately conveyed to the medical team looking after Eilis Cronin Walsh.
After two telephone calls from the hospital laboratory to her ward were not answered, no further effort was made to contact the team. The ward, the inquest was told, was five minutes walk away from the laboratory.
Surgeon Donal Maguire said the results indicated that Ms Cronin Walsh had developed an internal bleed and that if the medical team had been notified it would have triggered an intervention.
The failure to ensure that the abnormal results were conveyed to the medical team was contrary to protocol at the time and has led to a review and new measures being introduced, the inquest was told.
The test results were available soon after noon on Sunday, October 17th, but only brought to the medical team’s attention seven hours later when a nurse decided to check them on the hospital system. Immediately measures were taken to treat Ms Cronin Walsh but she was declared dead soon after 9pm that Sunday.
Mr Maguire said the blood results indicated that Ms Cronin Walsh must have had a minor internal bleed overnight on the Saturday but there were no blood pressure, pulse or other changes that would have triggered an alarm.
Then, on the Sunday, she collapsed when there must have been a “massive bleed” after an artery ruptured. It was not “a foreseeable deterioration” prior to that, he said. The rupture may have been caused by a number of factors, including abdominal infection and the leakage of pancreatic enzymes.
Asked by barrister Joe Brolly, for the family, if, by the time he was contacted on the Sunday, it was “too late”, Mr Maguire said “correct”.
James Walsh, husband of the deceased, said he and his son Kyle had visited Ms Cronin Walsh on Saturday, October 16th, and found her to be very weak.
“Before we left, Eilis said to me that she was not going to make it,” Mr Walsh said. He said he told his wife she would be getting stronger every day. “She said, no, her body was telling her, ‘I’m dying’.” That was “the last thing I heard from her,” he said.
Barrister Caoimhe Daly, for the hospital, said it wanted to express its sincere apology for the failure in care that occurred in the wake of Ms Cronin Walsh’s surgery and acknowledge the distress of the family.
She told coroner Aisling Gannon that the legal definition of medical misadventure did not denote blame and was an appropriate verdict for an unintended outcome of an intended act. Ms Gannon, making a finding of medical misadventure, said the intended act in this case was the surgery.
Speaking outside the court, Kevin Walsh said the family wanted to acknowledge the apology from the hospital and the changes that had been implemented since his mother’s death.
“I hope no other family has to go through this,” he said. “Eilis was a wonderful mum and a great human being. It is sad to see such a lovely person die so young.”