Coroner claims 74-year old was ‘not given a chance’
Ciara Galvin and Neill O’Neill
A series of tragic events which led to calls for an urgent ambulance transfer not being categorised correctly by the Emergency Medical Controller at The National Ambulance Control Centre in Castlebar were outlined at an inquest last week, into the death of Mr Eneas McDonnell of Erriff, Leenane, Co Galway, in Mayo General Hospital, on August 17, 2012.
Mr McDonnell, an extremely well-known and highly thought of man in his community and the wider Westport and north Connemara areas, presented with shoulder pain and shortness of breath after feeling unwell while checking stock on his farm that evening. He had been unwell earlier in the week but was described as being in good form that day. A neighbour brought him to Mayo General Hospital around 8.40pm that evening.
He was seen immediately without having registered at the desk and the Medical Registrar in the accident and emergency unit in Mayo General Hospital (MGH) had been advised by the Cardiology Registrar on call in Galway University Hospitals (GUH) to immediately transfer Mr McDonnell to the Cardiac Centre of Excellence in GUH, and according to national guidelines he had to be there within 90 minutes of having been diagnosed, or else he would have to be thrombolysed (have a clot busting drug administered) and stabilised before he could be transferred for urgent treatment.
'This is a dire emergency'
Nursing staff at the hospital made repeated attempts to acquire an ambulance from the National Ambulance Service in Castlebar, but were told no ambulance would be available until 11pm. A recording of the request from a Clinical Nurse Manager in MGH was played at the inquest during which she states “he needs to go now, blue light kind of thing.. this is an emergency emergency you know.. this is a dire emergency.”
There were two ambulances outside the emergency department at MGH while this was occurring, but the crew had not been declared clear of their last calls.
It took four phone calls before the third operator she spoke with - the ambulance dispatcher - send an ambulance that was idle at the base at the time of the first call. It transpired that the two other 999 operators - one relatively new to the position - were busy dealing with a unique incident in Clifden which involved a car crash and electrocution. The operator who took the call about Mr McDonnell said his attention was fixed on the incident in Galway, and his ‘mind wasn’t on the job at the time’, that he was ‘influenced’ helping his colleague handle her first serious call.
A fault which came to light was the failure of the call for an ambulance not being registered as an emergency. The inquest was informed that because the nurse did not use the relatively new code words (CODE STEMI), which would have dispatched an ambulance to the hospital straight away, instead the call was registered as urgent and the available ambulance at the Sacred Heart Home was not dispatched.
The inquest heard that this was the first time a call requiring the use of the new code, which was introduced in July 2012, was received by the ambulance centre.
As there was no available ambulance to take Mr McDonnell to Galway within the crucial 90 minute period for treating him, the doctor and staff were advised in a subsequent call with the Cardiology Registrar in GUI to administer clot breaking medication (thrombolysation). Although a private ambulance, organised by the McDonnell family was arranged at this stage, Mr McDonnell could not be transported until he stabilised after the thrombolysis. Subsequently, at 9.40pm, Mr McDonnell went in cardiac arrest and despite continued efforts of resuscitation, he was pronounced dead at 10.20pm.
The inquest was made aware that by the time the HSE dispatcher sent the ambulance, Mr McDonnell could not be moved as thrombolysation had commenced.
It was heard that hospital staff were complying with guidelines stating that someone who presents with chest pain must be brought to primary care centre such as University Hospital Galway within 90 minutes of an ECG being performed. If the patient cannot make one of these hospitals within 90 minutes, medication (thrombolysation) is to be administered at the hospital, until the patient stabilises and can then be transferred.
'Impossible and unrealistic task'
Mr O’Dwyer told the inquest on numerous occasions that 90 minutes to ensure a cardiac patient in Mayo reaches the hospital in Galway was an ‘impossible’ and ‘unrealistic’ task to meet.
Commenting on the majority of the evidence heard, Mr O Dwyer said he found ‘unnerving, the level of support available to patients in hospitals’.
Paudie O’Riordan, Area Operations Manager for the National Ambulance Service West, told the inquest that although the default code was not given, the call should have been recognised as a (CODE STEMI) and an ambulance should have been dispatched. He explained that investigations and reviews had found that policies had not been followed in this instance, but had been for similar calls since Mr McDonnell’s death.
Pathologist, Dr Thomas Nemeth, told the inquest that Mr McDonnell had died by natural causes and thrombolysation was ineffective in treating him.
Mr O’Dwyer described the inquest as a ‘very sad and tragic death’ and told the McDonnell family that he hoped Mr McDonnell had not died in vain.
Referring the medical staff at Mayo General Hospital, Mr O’Dwyer was fulsome in his praise and said he was satisfied that the hospital dealt with Mr McDonnell appropriately and promptly. He added that although he was not indicating Mr McDonnell would have survived if an ambulance was dispatched, he was still ‘not given the chance’.
He offered his sympathies to the McDonnell family, who did not wish to comment, except to thank all the medical staff at Mayo General Hospital for the work they had done and their efforts to save their father.
Seperately, a remark about coronary care at MGH by Coroner John O’Dwyer has prompted a response from the HSE.
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