MRSA death not reported for 12 days
A breakdown in communications between administrative staff, consultants and junior doctors at Mayo General Hospital (MGH) led to the death of a patient from MRSA not being reported to the coroner, as should happen.
The General Manager of MGH, Mr Tony Canavan, admitted the failure – the second in the space of a year – at the inquest yesterday (Monday) into the death of 82-year-old Mr John Deane of Kildaree, Crossmolina who contracted MRSA in the hospital while he was recovering from a broken hip. Mr Deane was admitted to hospital after breaking his hip on August 6 last and contracted MRSA on August 15, before dying from MRSA pneumonia on Friday, September 7 last.
Following Mr Deane’s death, a number of hospital procedures were not adhered to by consultants, registrars or junior doctors. Dr Ahmed Kharief Omer, a Senior House Officer in the Orthopaedic Department, admitted he failed to seek advice from a senior member when filling in the death certificate, when he recorded the death as multi-organ failure instead of MRSA pneumonia. He also failed to notify the coroner of the death and admitted he did not know at the time it was the hospital’s policy to contact the coroner. When Mr Omer’s mistake was noticed by senior members of the Orthopaedic team, the correct death certificate was only rectified 12 days after Mr Deane’s death and they still failed to contact the coroner. It was revealed by Mr John O’Dwyer, Coroner for South Mayo, that the inquest only occurred after he was told about the death by a registrar in the Births, Deaths and Marriages office in Castlebar.
Mr Canavan explained that following a similar inquest earlier in the year, a letter was circulated to senior consultants and nurses outlining the hospital’s policy of notifying the coroner of a MRSA death.
He said there were 88 non-consultant doctors in the hospital and it was impossible to provide induction courses to all of them and it was up to the senior consultants to explain the hospital policy to them. He admitted that there appeared to be a breakdown in communication and said in the future consultants will be told to ensure all junior doctors are informed of hospital procedure.
Mrs Helen Leonard, daughter of Mr Deane, told the inquest that following the operation he was put into a single bed ward because he had become agitated. She said on Wednesday, August 15, she was informed he had contracted MRSA and a gown and gloves had to be worn when entering the room. She said on August 19 he had another fall and he seemed to deteriorate little by little every day, and eventually died on September 7.
She explained that a few days later, her mother got a letter listing multi-organ failure as the cause of death and she enquired why MRSA was not mentioned. She said they later got a second death certificate form stating MRSA pneumonia was the cause of death.
Ms Bridget Hughes, Consultant Trauma and Orthopaedic Surgeon, who carried out the operation on Mr Deane, explained that it was a policy in the orthopaedic department to inform the coroner of every death. She admitted she did not know Mr Deane had died until the following Monday even though she was on call for the weekend.
Ms Hughes said the reason it took so long to change the death certificate was because they could not locate the death certificate book and the decision to change it was nothing to do with Mrs Leonard contacting the hospital. She said she did not contact the coroner because she was confident her diagnosis was right and thought the only time to contact him was immediately after the death.
Dr Ahsan Alam, Registrar to Ms Hughes, admitted they had made a mistake and the courteous thing to do would be to inform the family of the error and he said they would do so in the future. Dr Omer said he had told the registrar on call, Mr Rauf Abdul, to tell Ms Hughes of Mr Deane’s death, but Mr Rauf said that he thought Dr Omer would tell her and he also assumed he had contacted the coroner.
Mr Peter Flynn, solicitor for the Deane family, said they were happy with the care Mr Deane got from the hospital but were very affected by what happened since. He said the scenario for what unfolded at the inquest spoke for itself.
Mr John O’Dwyer extended sympathy to the Deane family and said he hoped he had not put the family through too much trouble. He said he was satisfied that Mr Deane died of MRSA which he contracted in Mayo General Hospital.
Mr O’Dwyer said it was the second time in a year this had happened and hoped no other family would be put through the same procedure. He added that management had sought to educate the staff and the problem was not administrative, but clinical.
Superintendent Eugene Brennan and Mr David Richardson BL, for Mayo General Hospital, extended their sympathies to the Deane family, while Mr Flynn thanked the coroner, the hospital and the Gardaí on behalf of the family.
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