An inquest into the death of Sally Maaz, the 17-year-old Co. Mayo student who died while an inpatient at Mayo University Hospital two years ago, concluded in disorder on Monday afternoon as three members of the public were removed from the courtroom by gardaí.
While in hospital, Ms Maaz was diagnosed with Covid-19. Covid was diagnosed as the medical cause of her death.
Martina Burke, along with a son, Josiah, and a daughter, Jemima, shouted from the body of Swinford Courthouse after the Coroner for Mayo returned a verdict of death from natural causes.
After the Coroner for Mayo Pat O’Connor returned a verdict of death from natural causes, Burke family members heckled him, claiming the proceedings were “a disgrace” and that the Maaz family had been “deceived” by gardaí.
When the Burkes loudly persisted with their complaints and condemnation, they were removed one by one from the hearing.
Last February, at the initial stages of the inquest, they were also expelled from the proceedings.
Medical history
Closing legal submissions in the inquest hearing on behalf of the hospital and the HSE and the Maaz family had been heard last month.
In his closing submission, Conor Bourke SC, for the hospital and HSE, referred to Ms Maaz’s previous medical history.
He outlined that shortly after her birth she was referred to Crumlin Hospital where she was diagnosed with pulmonary atresia and a univentricular heart, for which she underwent multiple surgeries and procedures.
Mr Bourke referred to medical evidence which was given to an earlier inquest hearing which outlined that the teenager’s ventricular function had clearly begun to deteriorate in the six months prior to her death.
It was very uncertain whether she would have been considered suitable as a heart transplant recipient.
Mr Bourke submitted that the coroner’s verdict should be death by natural causes.
“It is further respectfully submitted that there is no basis for a finding of death by misadventure,” counsel stated.
In his submission on behalf of the Maaz family, Johann Verbruggen said the appropriate verdict was medical misadventure.
“It has to be borne in mind that Sally spent the last six days of her life with this infectious disease (Covid-19), untreated, and this we say is a misadventure”, the submission stated.
Mr Verbruggen said the family had concerns that this would be recorded as a verdict of death from natural causes given all the evidence that had previously been heard.
In his submission, Mr Verbruggen said that a verdict of death from natural causes would “fail to account for the considerable and important evidence of the circumstances and the risks that arose in Sally’s care, exposing her to the virus that killed her”.
Before delivering his verdict on Monday, the coroner said that Ms Maaz had contracted Covid-19, a communicable disease. Nobody can definitively say where or when they contracted the disease.
The coroner made a number of recommendations arising out of the case.
He suggested an expert group be established by the Government to review the manner in which the State, particularly the Department of Health and the HSE, dealt with the Covid-19 pandemic in Ireland with a view to learning lessons and ensuring that the State is adequately prepared for any further pandemic.
Mr O’Connor also asked that the HSE, Mayo University Hospital and the Saolta Group take careful note and learn such lessons as are appropriate from the evidence heard at the inquest.
The coroner also recommended that appropriate communication and notification in writing take place between medical clinicians on the handover of care by them to others of any patient in the hospital.
Mr O’Connor recommended that the hospital, in consultation with Saolta and the HSE, puts in place, if not already in place, clear lines of responsibility for the care of patients by all clinical staff.
He said such protocols as are in place should be the subject of full and proper training and awareness meetings involving all appropriate staff.
Finally, the coroner urged that the protocols in the hospital for liaising with members of a patient’s family be reviewed and updated.