‘Had Bryonny been treated appropriately in Mullingar ...she would not have died’
Verdict of medical misadventure given in death of rider
THE death of a young woman who experienced ‘a catalogue of failures’ while in hospital after being kicked by a horse was due to medical misadventure, a coroner has ruled.
Bryonny Sainsbury, 25, a salon owner from Briskil, Newtownforbes, Co. Longford, who suffered a serious brain injury, died in Beaumont Hospital in Dublin on August 31, 2021.
Ms Sainsbury sustained her injuries while holding her horse as a vet tried to put a tube into the animal’s mouth at a riding stables in Keenagh, Co. Longford on August 26, 2021.
She was initially brought to hospital in Mullingar and was only transferred to Beaumont three days later after a serious deterioration in her condition.
Following two days of evidence from over a dozen witnesses at an inquest at Dublin District Coroner’s Court, coroner Cróna Gallagher returned a verdict of medical misadventure.
Counsel for Ms Sainsbury’s family, barrister Esther Earley, said the combination of failures and shortcomings in the care of the patient during her stay in Midland Regional Hospital in Mullingar had led to a death which was ‘treatable and salvageable’.
‘Had she been treated appropriately in Mullingar, she would not have died,’ said Ms Earley.
The barrister claimed the evidence had demonstrated that staff in Mullingar had failed to keep experts they consulted in Beaumont apprised of changes in the patient’s condition which she said had begun early on August 27, 2021 when Ms Sainsbury was vomiting and complaining of the pain in her head. She said they had also failed to inform staff in Beaumont of the results of various scans on the patient.
Ms Earley acknowledged there was a dispute between the two hospitals over advice that had allegedly been given for regular checks to be carried out on Ms Sainsbury which would have highlighted her falling sodium levels.
The barrister said there was also confusion between consultants in Mullingar over who was responsible for the care of the patient at a time when it was obvious that her condition was deteriorating.
She noted that one witness – a consultant neurosurgeon at Beaumont, Donncha O’Brien – had given evidence that his medical team were powerless to act to treat Ms Sainsbury due to lack of communication by staff at Mullingar and not following the advice given by colleagues in Dublin.
Ms Earley criticised the system which seemed to exist in Mullingar where there was ‘a fundamental breakdown’ over who was responsible for the patient’s care.
She said such a system ‘can’t be acceptable or safe’.
Counsel for the Midland Regional Hospital in Mullingar, barrister Caoimhe Daly, had called for a narrative verdict to reflect what she claimed was the complexity of the case as well as to explain how Ms Sainsbury had sustained her original injury. She was supported by solicitor for Beaumont Hospital, Kevin Power, who claimed a finding of medical misadventure would be ‘a blunt tool’ which could not encapsulate ‘the full picture’.
Earlier, Dr Gallagher observed that she had heard ‘diametrically opposite’ evidence about who had responsibility for the care of Ms Sainsbury over the weekend she was in the hospital in Mullingar.
‘There is a problem if two people each thought the other was in charge,’ Dr Gallagher said.
A consultant surgeon on call in Mullingar at the time, Shahbaz Mansoor, gave evidence that Ms Sainsbury was not his patient but he was available to treat her if requested. However, another consultant surgeon, Muhammad Majeed, under whose care Ms Sainsbury was admitted to the hospital, told the inquest yesterday that he expected Prof. Mansoor would have been called about the patient if needed as he was off-duty over the weekend.
‘Fighting to get answers’
In reply to questions from the coroner, Dr Majeed said he believed the ultimate responsibility for the patient rested with the on-call consultant in Mullingar.
Returning a verdict of medical misadventure, Dr Gallagher recommended that the Midland Regional Hospital in Mullingar should carry out a review of its oncall arrangements.
Welcoming the verdict, Bryonny’s mother Alison Sainsbury said it had been a long while ‘fighting to get answers why our daughter died and why she didn’t get the adequate medical treatment that she should have had for the injury she sustained’. The family said they would be taking further action over the circumstances of their daughter’s death.