Failings to administer medicine at Daisy Hill highlighted during inquest

Wednesday, 31 May 2017

AN INQUEST into the death of a Warrenpoint woman has heard that while no direct fault came from hospital staff while she was under their care, there were some failings on the part of the Southern Health and Social Care Trust.

Patricia McCoy-Lavery was 73 when she passed away in Daisy Hill Hospital on 22 December 2012.

Mrs McCoy-Lavery, who lived on the Rostrevor Road had suffered from hypertension, osteoporosis, polymyalgia and fibromyalgia.

She sought medical help in 2012 when she developed right upper quadrant pain and was referred for consideration of an Endoscopic Retrograde Cholangiopancreatography (ERCP) procedure, after an ultrasound scan showed stones within her gallbladder, in addition to the thickening of its walls.

ERCP is a technique which combines the use of endoscopy and fluroscopy to diagnose and treat certain problems of the biliary or pancreatic ductal systems.

Due to Mrs McCoy-Lavery's own health problems, it was felt she was not a good candidate for surgery, which was why she was recommended for the ERCP.

The ERCP was performed in October 2012 when small stones were present within the duct and "one 3mm balloon pulled through". A review was to be performed six weeks after the procedure.

Coroner Mr McGurgan said he found the decision to perform an ERCP was "en - tirely appropriate" and in addition to this, the placing of a stent "was neither required nor appropriate".

Mrs McCoy-Lavery was reviewed on November 2012 when she was still complaining of bouts of right upper quadrant pain, radiating around to her back. It was subsequently decided that a repeat ERCP would be performed.

This was carried out on 13 December 2012 and "stones were noted in the gallbladder".

While Dr Charles O'Brien, consultant physician and gastroenterologist, carried out the procedure and said he "trawled the bile duct for some six minutes using the balloon catheter" to ensure the bile duct was cleared of all stones.

The inquest heard that Dr Adrian Hatfield, consultant gastroenterologist, was of the opinion that "one could not clearly see the stone on the images taken during the operation" as the "bile duct was full of contrast and almost certainly obscuring the stone" which "could be seen on all other images".

Dr Hatfield considered it "highly likely" that a stone was left behind at the end of the procedure.

However, at their inquest these images were reviewed by Dr O'Brien and Dr Tony Tham, consultant physician and gastroenterologist, and coroner Mr McGurgan found that "on the balance of possibilities" that "there was no stone left behind at the end of the second ERCP procedure".

Mr McGurgan said this was supported by the fact there were "no stones in the bile duct at autopsy".

Mrs McCoy-Lavery was due to be discharged from Daisy Hill Hospital the day after this second ERCP was carried out, however the inquest heard she was reporting pain following the procedure and was feeling unwell.

She was admitted onto Female Medical Ward for observations, with Dr O'Brien holding the view thiswas a simple precautionary measure as pancreatitis (inflammation of the pancreas) is a common complication following an ERCP.

Mr McGurgan noted Mrs McCoy- Lavery was to remain overnight and was prescribed Cyclizine and Tramadol, however while the Cyclizine was administered, the Tramadol was not.

Mr McGurgan told the inquest that failing to administer the Tramadol or an alternative pain relief was "a failing on the part of the Trust".

"On initial admission to the Female Medical Ward (at approximately 7.15pm) Tramadol which had been prescribed but not administered in the Day Care Centre, was not administered nor was alternative pain relief administered.

"In fact the next pain relief administered was at 11pm and it was accepted by Mr Carroll (Assistant Director of Acute Services with the Southern HSCT) and I find that this delay was a failing on the part of the Trust," said Mr McGurgan.

Initial observations carried out on four occasions between 5pm and 7pm on Mrs McCoy-Lavery also recorded a National Early Warning Score (NEWS) of zero.

This was also the case at another observation at 7.15pm, however her blood pressure was 208/90 and the admitting nurse on the ward had advised that "hourly observations should be performed".

"The NEWS guidelines required that observations were taken 12-hourly, but the nurse caring for the deceased exercised judgment and decided to adopt hourly observations, but then failed to follow this through, with the next observation being three hours," said Mr McGurgan.

He noted that when the next clinical observations were recorded at 10.20pm the NEWS was at seven.

"In accordance with the NEWS escalation pathway, a doctor was informed and he reviewed the deceased at 10.30pm," he said.

"As required, observations were then recorded at 15-minute intervals and by 11.10pm, the deceased's NEWS had increased to 10. There was evidence of septic shock and secondary renal failure.

"I find on the balance of probabilities that once the admitting nurse had advised that hourly observations were required, then they should have been so undertaken.

"I find that the failure to undertake these hourly observations, resulting in two missed observations, represented a loss of opportunity in the care of the deceased," he said.

"However it is impossible to determine on the evidence that if these observations had been performed at the appropriate times, the outcome for the deceased would have been any different." Mr McGurgan recognised also that "spontaneous infection" following ERCP was a "recognised complication of such a procedure".

"I find on the balance of probabilities that the treatment provided to the deceased in the High Dependency Unit was entirely appropriate and that the deceased had reached the point of no return by 3pm on 14 December 2012," he said.

Mr McGurgan recorded the cause of death as ascending cholangitis, following Endoscopic Retrograde Cholangiopancreatography (ERCP), complicated by acute renal failure.


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