A JURY has returned a verdict of "death by misadventure" in the case of a man who died on an operating table in St Vincent's Hospital, Dublin.
The Dublin Coroner's Court heard that Mr William O'Brien (77), of Cullenswood Gardens, Ranelagh, died during an operation on November 17th, 1995. The jury accepted evidence by a pathologist that the immediate cause of death was haemodynamic shock following uncontrollable bleeding from an artery in his chest.
Mr O'Brien had been undergoing surgery to remove a severe stricture in his trachea. The surgery had been underway for several hours when there was sudden massive bleeding.
Dr Vincent Lynch, a consultant cardiothoracic surgeon at St Vincent's, said he had "virtually completed" the operation when the fatal haemorrhage occurred. The surgery had gone very well and all the difficult parts had been completed, he believed.
He looked up from the table for "one or two seconds" to ask the anaesthetist to move a tube, and when he looked back there was bleeding from an area "three to four centimetres" from the site of the operation. "I couldn't believe it," he said. "I hadn't been cutting anything and there was no reason for it."
Dr Lynch said the wound was in the brachiocephalic artery, near the junction with the aorta, and he estimated the patient had been losing about a pint of blood a minute. His first reaction was to stem the blood by "putting a finger in the hole to try and stop it." When this didn't work, he "split the whole sternum open" to get better access and attempted to suture the wound. But the patient's heart stopped and attempts to restart it failed.
Dr Lynch said Mr O'Brien had been a very sick man at the time of the operation. In repeated visits to hospital during the previous two years, he had undergone a colostomy, a tracheostomy, and an operation on his stomach for peritonitis. He had developed a hernia and suffered a stroke during the same period.
Arterial disease had weakened the walls of his arteries to the point where a rupture could occur and, although the operation was a dangerous one for a man in his condition, it was necessary because he was in severe respiratory distress. The stricture in his trachea had narrowed the passage to 10 per cent of its normal size - the width of the "head of a match stick," Dr Lynch said.
Dr Jessy Jacob, the pathologist who carried out the post mortem, said Mr O'Brien's brachiocephalic artery had been completely severed.
The coroner, Dr Brian Farrell, told the seven person jury that the verdict of "death by misadventure" was similar to accidental death but carried no connotations of blame or wrongdoing, "nor does it exonerate anyone."
