An inquest into the death of a 25-year-old Co Longford woman who died after suffering a kick to the head from a horse has recorded a verdict of medical misadventure.
Dublin District Coroner’s Court heard that Bryonny Sainsbury, from Briskil, Newtownforbes, may have been saved but for a lack of communication from staff at Regional Hospital Mullingar regarding her condition, according to a consultant neurosurgeon at Dublin’s Beaumont Hospital.
Advocating for a verdict of medical misadventure at the court sitting, Esther Earley BL, acting for the bereaved family and instructed by solicitor Karen Clabby, contended that a “catalogue of failures” at the Co Westmeath hospital “combined to cause [Ms Sainsbury’s] death”, including a failure to follow specialist advice provided by physicians at Beaumont Hospital.
Describing Ms Sainsbury as “vibrant, healthy, loving”, Alison Sainsbury, the deceased’s mother, said Wednesday’s verdict came after “2½ years of fighting, trying to get answers why our daughter died and didn’t get the adequate medical help that she should have had for the injuries she sustained”.
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“To be told, first of all, that your daughter had died, and then to find out 2½ later that with a simple medical intervention, she could be here, you can’t put it into words. It’s life-changing,” she said, standing outside Dublin Coroner’s Court on Store Street. “We shouldn’t have had to live through what we lived through, to watch our daughter die.”
Ms Sainsbury’s father Christopher and Gregory, her brother, were also present in court.
In an incident at a riding stables in Keenagh, Co Longford on August 26th, 2021, Ms Sainsbury was kicked in the head by her horse while assisting in a veterinary procedure. She was subsequently admitted to hospital in Mullingar.
She later died from severe craniocerebral trauma at Beaumont Hospital on August 31st, 2021.
On her initial admission to hospital, staff at Mullingar sought advice on treating Ms Sainsbury from specialists at Beaumont Hospital.
However, Ms Earley contended that some of the advice provided by staff at Beaumont was not followed – including an instruction for Ms Sainsbury’s electrolytes be maintained and checked regularly in order to monitor her sodium levels. Ms Sainsbury’s bloods were taken on her initial admission to hospital, but were not checked again until after 11am on August 29th.
Low sodium levels in a patient point to a possible neurological problem, the court heard.
Although it was contested that staff at Mullingar had received the advice, Ms Earley noted that documentary evidence of the advice provided by Beaumont staff was available to the court.
Ms Earley said that in his evidence to the court on Tuesday, Prof Donncha O’Brien, a consultant neurosurgeon at Beaumont Hospital, said that Ms Sainsbury’s condition was “treatable” and “salvageable”, but that he was “powerless to act” in treating the deceased because of a lack of communication from staff at Mullingar regarding Ms Sainsbury’s condition.
She also noted Prof O’Brien’s evidence that had he seen CT scans taken of Ms Sainsbury’s brain on August 28th, he would have requested that she be transferred to Beaumont Hospital. Ms Sainsbury was not transferred to an Intensive Care Unit (ICU) until 2.45pm on August 29th, before being moved again to Beaumont Hospital.
The court also heard that there was no consultant handling the care of Ms Sainsbury from the evening of August 27th to August 29th, and so, Ms Earley said, there was a failure to escalate her care when her condition deteriorated.
In his evidence to the court, Dr Muhammad Majeed, a consultant at Mullingar Hospital, said that because he was not on duty on the weekend in question, Ms Sainsbury’s care was the responsibility of the on-call consultant.
However, the court heard that the consultant on call, Dr Shahbaz Mansoor, said Ms Sainsbury was the responsibility of Dr Majeed because she was admitted under his care on August 26th.
Dr Cróna Gallagher, the presiding coroner, noted that there was a lack of clarity between the consultants as to what the local practice was, and following her verdict, recommended that a review of formal and informal arrangements between consultants at the hospital be carried out.
Ms Sainsbury’s condition deteriorated on the morning of August 29th, the court heard. After 5.30am, Megan Ryan, a staff nurse, observed Ms Sainsbury walking around her room in the hospital “completely disorientated”. Ms Ryan told the court that Ms Sainsbury was unable to answer basic questions, such as what her name was.
Ms Sainsbury was later given a sedative and sent for a CT scan by Dr Ismal Saleem, a senior house officer, who had come to assess her around 6am. He told the court that he believed the scan report was stable.
Results of a blood test on Ms Sainsbury, made available at 12.40pm, showed a significant drop in her sodium levels, the court heard.
In a conversation with consultant anaesthetist Dr Kamal Abouhajar, Camilla Murray, a senior nurse at the hospital, said Ms Sainsbury should be transferred to ICU, she told the court. Dr Abouhajar carried out a Glasgow Coma Scale (GCS) examination of Ms Sainsbury and concluded that she did not require transfer to ICU.
Ms Murray said she did not believe the GCS reading was accurate, and said that she expressed concern about Ms Sainsbury’s sodium levels.
Dr Abouhajar previously gave evidence to the court rejecting the claim he was informed of Ms Sainsbury’s sodium levels at that point.
Ms Sainsbury was eventually transferred to ICU at 2.45pm, where she suffered a seizure, and her GCS score dropped to four.
She was then transferred to Beaumont Hospital with severe swelling to the brain. She died two days later, on August 31st.
Dr Gallagher expressed her condolences to the bereaved family on the conclusion of the inquest. “I’m sure the loss is felt very acutely by you every day,” she said.
Lawyers for Regional Hospital Mullingar and Beaumont Hospital also expressed their condolences on behalf of their clients.
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