The circumstances surrounding the death of a man who lay undiscovered for more than an hour at the emergency department of University Hospital Limerick (UHL) have been described as “very serious” by Minister for Health Stephen Donnelly.
Mr Donnelly is due to visit the hospital next week alongside Health Service Executive chief executive Bernard Gloster, after an inquest on Wednesday heard Martin Abbott (65) may have been dead more than an hour and rigor mortis – where joints stiffen after the time of death – had set in by the time he was discovered face down by nursing staff.
He had fallen from a trolley that he had been lying on for three days in UHL’s emergency department in December 2019.
“I think it’s a very serious situation. The chief executive, Bernard Gloster and I were discussing it this morning, He and I are going to be in UHL next week,” Mr Donnelly said on Thursday.
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The Minister said there have been various inquests concerning the hospital. “Certainly, the situation there where the patient was on the floor for that extended period of time, nobody could stand over that. That’s obviously something that nobody would want to see,” he said.
UHL was asked for comment regarding the planned visit and the circumstances surrounding Mr Abbott’s death. “UL Hospitals Group wishes to express its sincere sympathy with the family of Mr Abbott on their loss,” a spokesman said.
“We strive to uphold the highest standards of patient care and safety, and it’s clear in this case, these standards fell short of what was expected. We apologise for the deficiencies and shortcomings in Mr Abbott’s care and for the distress and trauma this has caused his family,” he added.
Mr Abbott’s daughter, Ann Marie Abbott, told the inquest she wanted the circumstances of her father’s death to act as an urgent catalyst for change in the health system.
“I just do not know how many more people have to die before the system changes.”
“Dad’s death should not be in vain, but serve as a catalyst for meaningful change and improvements in healthcare practices and management to ensure the well-being and safety of all patients,” she said.
Mr Abbot presented at the hospital with pain, fever and diarrhoea, and he had previously received a kidney transplant. Due to steroid medication and anti-rejection medicines he had been on at the time, he was considered immunosuppressed and was placed on his own in a cubicle in the emergency department.
When he was discovered lying face down on the floor beside his trolley in the early hours of December 17th, the former taxi driver could not be ventilated by a doctor as rigor mortis had set in.
Pathologist Dr Gabor Laskai told the inquest rigor mortis usually sets in two hours after death, however it could occur more quickly, due to fever, severe shock or sepsis.
According to Dr Laskai, death was caused by acute heart failure against a background of pneumonia, severe arteriosclerosis and hypoxia. Mr Abbott was receiving different antibiotics to treat a Legionella infection that had caused pneumonia in his lungs.
Coroner John McNamara recorded a verdict of death by medical misadventure.
Mr McNamara noted UHL “is in the news for all the wrong reasons” in respect of overcrowding.
Mr Abbott from from Deilginis, Shannon, Co Clare is one of a growing number of patients who have died in tragic circumstances at UHL amid a background of persistent overcrowding.
Mr Abbott’s death prompted a full systems analysis review at UHL, and an external report into his death delivered 26 recommendations, many of which identified overcrowding in the hospital as a serious issue.
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