A verdict of medical misadventure has been recorded at an inquest into the death of a man who did not receive prescribed anticoagulants for blood clots which ultimately led to his death at a Dublin hospital.
A sitting of Dublin District Coroner’s Court heard that Derek O’Neil attended St Vincent’s University Hospital shortly after 12.30pm on October 22nd, 2022 suffering breathing difficulties and chest pain.
The 53-year-old had been experiencing the symptoms for four weeks which had worsened in the days before attending the emergency department.
Dr Mugtaba Ahmed who was a registrar in emergency medicine at the hospital at the time, said he attended Mr O’Neill first at about 1pm, though the hospital records did not reflect this.
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Medical notes entered at 4.45pm outlined a treatment plan which included anticoagulation therapy in the form of Tinzaparin alongside a CT pulmonary angiogram.
The inquest heard that Tinzaparin was not prescribed until between 9pm and 9.30pm, after which a nurse was informed in order to have it administered. However, it was never actually administered to Mr O’Neill.
Asked by coroner Dr Claire Keane if there was a reason the prescription had not been written at 4.45pm, Dr Ahmed who now works in Brooklyn, New York said he could not remember why.
He added that he was not sure why the medication had never been administered.
CT results received at about 9.30pm confirmed bilateral pulmonary emboli, and Mr O’Neill was placed under closer observation.
Shortly before 11pm, Mr O’Neill became unresponsive, prompting resuscitation attempts alongside the administration of thrombolysis to break down the clots.
Despite ongoing CPR, Mr O’Neill was pronounced deceased shortly after midnight on October 23rd.
The medical cause of his death, which sparked an internal review, was recorded as bilateral pulmonary emboli.
Dr Patrick Hillery, a consultant in emergency medicine, said he could not say for certain whether the administration of Tinzaparin would have changed the outcome.
Although not all facts could be established, such as whether Mr O’Neill had been seen at 1pm as claimed, Dr Keane said the “crux of the matter” was that it was determined at 4.45pm that Mr O’Neill was to be administered anticoagulation medicine.
Based on the evidence outlined, including the delay in writing the prescription, and the fact the medication was never administered, Dr Keane returned a verdict of medical misadventure before endorsing recommendations made by the hospital following a review.
These include the provision of education sessions in the emergency department concerning the management of patients presenting with high suspicion of pulmonary embolism.
Although noting there are specific policies concerning communication between staff, Dr Keane said she would issue a recommendation to the hospital concerning “the action of communicated results” in the event of potentially life-threatening conditions.
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