A Clinical Director who carried out a report into the sudden death of a 19-year-old Lithuanian woman who died in Mayo General Hospital told her inquest that the outcome would have been the same regardless of the care she received.
Justina Kriaciunatie died on November 10, 2010, less than 12 hours after she was admitted to Mayo General suffering from abdominal pains. Her family expressed their concern that she did not receive sufficient care in the hours before her death.
Ms Kriaciunatie had been initially diagnosed with Peptic Ulcer Disease, but in the early hours of November 10 her health deteriorated considerably and she was transferred to the Intensive Care Unit, where she suffered cardiac arrest and died.
Following her sudden death, Clinical Director of Mayo General Hospital, Dr Michael O’Neill decided to commission an external examination into the death of Ms Kriaciunatie. He said he did so not because of any failures on the medical team’s part, but because the sudden death of a young healthy woman had caused stress to the medical staff, and he wanted to see if they could learn anything from the incident.
Dr O’Neill explained that he asked Dr Colm Quigley, former President of the Medical Council and Clinical Director in Wexford General Hospital, to carry out the review because he did not want it to be considered a ‘whitewash or cover-up’.
The post mortem into the death of Ms Kriaciunatie found that she died of heart failure due to a ‘rare condition’ called myocarditis, which is regarded as one of the causes of Sudden Adult Death Syndrome (SADS).
Dr Quigley described the virus as a ‘catastrophic illness’ which was probably inhaled and circulated in the blood stream. “The failure to diagnose here is understandable,” Dr Quigley told the inquest. “This is a very aggressive illness which can be devastating and develop rapidly with little warning.” He said that ‘no treatment’ could have saved her.
“Even in a cardiology unit you would only be able to put in a balloon pump to keep the heart going for a transplant. But in this case you would need a heart and lung transplant, which would simply not happen anywhere in the world. She would not have lasted ten minutes in an ambulance to Dublin … Even if she fell ill outside the Mater she’d still have died.”
In his report, Dr Quigley said he had concern of the patient’s care from 3.15am to 6.40am, when Ms Kriaciunatie became ill. She was treated by Dr Ciara Curran, who was a trainee GP at the time. In her evidence, Dr Curran said she was getting all the information about Ms Kriaciunatie before she called Dr Montasir Bashery, the Medical Registrar.
Dr Quigley said it was common practice to have all the appropriate information available for the medical registrar but in a situation where the patient was getting rapidly ill a senior person should have been called during this time.
He explained that the HSE is currently looking to introduce early-warning systems in hospitals where a rapid response team would be called to deal with cases such as Ms Kriaciunatie to try an stabilise the patient. He said the problem was not just an Irish one and that these rapid-response teams were being introduced in the US and Australia.
The inquest was adjourned until October in order to hear from witnesses who had been unable to attend.