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Coroner calls for more transparency from HSE

Coroner calls for more transparency from HSE

Anton McNulty

THE  Coroner for south Mayo has called on the HSE and the State Claims Agency not to conceal hospital reports from inquests in the future and to be more open and transparent.
Mr John O’Dwyer, (pictured), the coroner for south Mayo made his comments at the conclusion of an inquest into the death of Justina Kriaciunatie - a 19-year-old Lithuanian national - who died from heart failure due to a ‘rare condition’ called myocarditis which is regarded as one of the causes of Sudden Adult Death Syndrome.
Following the sudden death of Ms Kriaciunatie, of 6 Ard Rua, Claremorris, in Mayo General Hospital in the early hours of November 10, 2010, the hospital carried out an investigation into the circumstances of her death. Mr O’Dwyer revealed that the HSE had initially declined to make the findings of the report available to the inquest and only agreed when Cathal Magee, CEO of the HSE was summoned to explain why the report was being concealed.
Mr O’Dwyer said he became aware that it is common practice for HSE and the State Claims Agency not to make reports available to coroners and called on them to review this practice.
“That is an unfortunate view to take and one I do not believe or accept,” he explained. “People in the county who use the hospital are entitled to know that the best practice is adopted and they get the best care and are treated to the highest standard. All I can do is to ask the HSE and the SCA to take a more open and transparent stance and anything that I interpret as concealed information will not be supported and I will oppose at every opportunity.
“If they have anything to hide, and I am not saying they have anything to hide in this case, they should tell it as it is. If they put their hands up to a mistake, people will be happier with the honesty and their openness,” he concluded.
Earlier the family of Ms Kriaciunatie called on the coroner to record a verdict of medical misadventure because they felt insufficient testing was carried out on their daughter in the hours prior to her death.
Ms Kriaciunatie died less than 12 hours after she was admitted to Mayo General suffering from abdominal pains and had been initially diagnosed with Peptic Ulcer Disease. However 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.
She was admitted into the A&E of MGH at 9.30pm and after initial examination it was recommended that she would be examined within the hour. However she was not seen until 11.55pm by Dr Samah Elhassan.
In her evidence she said she was satisfied with her initial diagnosis given the information she was given and there was no reason to suspect the patient was suffering from heart problems and did not entertain the idea of carrying out a electrocardiography (ECG).
Pathologist Dr Fadel Bennani, who carried out the post mortem explained that myocarditis is the inflammation of the heart muscle and is extremely rare. He said that he has come across four cases in the west of Ireland and on each occasion the findings come as a ‘surprise and shock’.
Dr Bennani explained that the theory is that myocarditis occurs three to four weeks after the patient suffers from a virus such as the common flu. He explained that after the antibodies attack the virus they think the heart muscle is the ‘enemy’ and attack the heart. He said that Ms Kriaciunatie would have suffered from the condition at least a week and a half before admission. He felt death was inevitable regardless of the treatment carried out in the hours beforehand.
The HSE had asked Mr O’Dwyer to record a verdict of death by natural causes but in his judgement he recorded a narrative verdict. He said the death was a tragedy for the parents Inga and Valdas Kriaciunatie who lost their only child and added that he too had been traumatised by the case.