Woman died after doctor on call was phoned four times
A DOCTOR on call was contacted four times by hospital staff who had concerns for a patient who later died, an inquest has heard.
Marian Tracy, 60, died four days after surgery to remove her thyroid was performed at St James’s Hospital in Dublin on May 14, 2015. Yesterday, a verdict of medical misadventure was returned at the inquest into her death.
In a statement, the Tracy family said they are devastated by their loss. ‘Marian was the heart of our family and her death has left a huge void in all our lives,’ they said.
‘We would hope that Marian’s death wasn’t in vain and the coroner’s recommendations be put in place and hopefully prevent another family having to suffer as we have.’
Ms Tracy, of Dodsboro Road, Lucan, Co. Dublin died as a result of a lack of oxygen to the brain due to compression of the windpipe caused by a clot following her thyroidectomy surgery.
Ear, nose and throat (ENT) registrar-on-call Dr Monica Istovan was contacted four times by staff and an intern doctor relaying concerns for Ms Tracy between 6.30pm and 11.04pm on May 15, 2015. Dr Istovan did not attend Ms Tracy in a private ward in hospital until after she had suffered a respiratory arrest.
Concluding a two-day inquest, Coroner Dr Myra Cullinane recommended that St James’s Hospital and the HSE review their position of consultants operating on-call services to multiple hospitals and consider having senior on-call staff on-site within the hospital.
The coroner recommended that hospital staff across all levels be enabled to contact senior staff directly and that neck-swelling after thyroid surgery should prompt early review by ENT staff.
Mrs Tracy developed swelling and difficulty swallowing and breathing the day after her surgery. Night nurse Sarah Keating contacted Dr Istovan, who was at home when she received the call at 9.45pm.
‘I was worried because I had never seen a patient post-operative with this level of swelling,’ Ms Keating told the court. Dr Istovan instructed the nurse to ask the surgical intern on call, Dr Michael Dowling, to assess the patient.
Asked if there was any way to over-rule the instructions of the registrar on call, the nurse replied: ‘It’s not really my call. It’s at her discretion.’
Dr Dowling reviewed Ms Tracy and was asked to send pictures of her wound to Dr Istovan’s phone.
When she saw the pictures, she said she would come in to see the patient. The hospital apologised to Ms Tracy’s family for the failings in her care.