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Verdict of medical misadventure in inquest into death of young Westport man


‘BEAUTIFUL SOUL’ The late Adam Mulchrone, a much-loved and talented footballer, whose passing has left an unfillable hole in the lives of his family.

MUH apologises ‘unreservedly’ after it failed to act adequately on meningitis concerns

Edwin McGreal


A verdict of death by medical misadventure has today (Tuesday) been returned at the inquest into the death of a young Westport United footballer.
Adam Mulchrone of Sandyhill, Westport, was aged 21 when he died at Mayo University Hospital (MUH) on January 27, 2019, just hours after being discharged after medics failed to diagnose meningitis.
Mr Mulchrone suffered multiple organ failure due to meningococcus septicemia as a consequence of a meningitis infection.  
In a letter read out at the conclusion of the inquest, Ms Catherine Donohoe, General Manager at MUH, said the hospital ‘unreservedly apologise’ for the level of care Adam Mulchrone received.
The talented footballer was initially sent to the hospital by Westdoc on January 26, after Westdoc doctor, Dr Raquel Caballero Pozo, expressed concerns he may have meningitis after Adam presented to her with a fever, vomiting, headaches and a stiffness in his neck.
However, meningitis was ruled out by the treating medic at Mayo University Hospital’s Emergency Department who sent him home with a prescription for paracetamol and ibuprofen.
Mr Mulchrone’s condition subsequently worsened at home and he was rushed to the hospital in the early hours of January 27, where he presented with organ failure. He was placed in intensive care, but his condition did not improve and he was pronounced dead later that evening at 4.42pm.

The second day of the inquest today heard from Westdoc’s Dr Pozo and MUH Consultant Pathologist Dr Tamas Nemeth.
Dr Pozo said she sent Adam to Mayo University Hospital because of fears he may have meningitis, and she described it as an ‘emergency’.
In response to questions from Ciarán Tansey, solicitor for the Mulchrone family, Dr Pozo said the most important medical intervention for someone with meningitis is an intravenous antibiotic, something which was not administered to Adam on his first visit to the hospital.
Mr Tansey asked is recognition of the possibility of meningitis in a patient ‘writ large in your profession’, to which she replied that it is.
Dr Nemeth said the infection Adam had is bacterial and is carried from person to person. Most people have no symptoms, he added.
Indeed, he said that in 25 years practice and over 4,000 post mortems, this was only the second death of this type he had encountered.  
Yesterday (Monday) Adam’s mother Mary Mulchrone questioned the care her son was given when he was first assessed in the emergency department. She believes that signs of meningitis were dismissed by the treating doctor.
She said that since Adam’s death, her family’s lives will never be the same again, and she is haunted by the hours she spent with him in hospital.
“The hours spent in the hospital that weekend will haunt us forever. He was a fit and healthy 21-year-old man, who was full of life and joy, and now he will never get to kick a football or laugh with his friends and family again. We are haunted by the memories of the hours we spent in hospital, worried for Adam as he was sick and weak,” she said.
She added that the impact of Adam’s death has been unimaginable and any amount of happiness they have still feels heavy and wrong because Adam is not there to share it with them.
“Our lives will never be the same again. Adam was a beautiful soul who was loved by many and was often described as a ‘true gentleman’. He was thoughtful, quiet and smart with so many skills and opportunities on the horizon.
“He had a good heart and would always be there whenever you needed him and wished the best for everyone. There was not a bad bone in his body. No words can ever sum up the pain and grief we feel after losing Adam. There is a hole in our lives that will never be filled.”
The Coroner for Mayo, Mr Patrick O’Connor was informed that the hospital has accepted that his vital signs should have been assessed before he was discharged at 7pm on January 26.
Dr Jason Horan, Consultant in Emergency Medicine in MUH, told the inquest that lessons have been learned and changes have been made to patient care following Adam’s death.
“The first learning was about the importance of checking for a second set of vital signs if you are considering if someone is suitable for discharge. This was particularly important, as shortly after Adam’s death we had the nurses strike, so it was important we enforced that message with doctors, and that is a message we continued on. This case does highlight how important a second set of vital signs is in trying to establish what may or may not be normal for an individual,” he said.

Failed to diagnose  
The inquest heard that Mr Mulchone went to the hospital on the afternoon of January 26 with his mother and his sister, Amy, and was assessed by Dr Georgios Diakidis, who at the time was an Emergency Department Registrar in MUH.
Dr Diakidis, who is now a consultant in emergency medicine, was not present at the inquest, but his deposition was read into the record.
He stated that on considering the potential diagnosis of meningitis/meningococcal septicaemia, he did a full neurological examination and he checked the body surface ‘from face to toe’ for any evidence to support it, such as neck stiffness and skin rash. He stated this was unremarkable with no signs of meningism or rash.
Dr Diakidis added that blood results were not consistent with a significant infection and that he reassessed Mr Mulchrone again at 7pm. He stated that Mr Mulchrone did not have any neck stiffness, and he believed it was unlikely he had meningitis at that point in time. His clinical impression was that he had a viral infection, such as gastroenteritis or influenza.
When questioning Dr Horan, Mr Tansey stated that meningitis had been diagnosed by the Westdoc doctor prior to Adam’s first visit to MUH, and by the medical team following his second admission. He asked Dr Horan why the emergency department had failed to notice what he said were up to nine signs of meningitis.
Dr Horan did not agree that all the symptoms were signs of meningitis at the time, and said that from reading Dr Diakidis’s medical reports and clinical notes, he did not believe the assessment to discharge was wrong.
However, Mary Mulchrone was critical of the care given to her son by Dr Diakidis. She claimed her son informed the doctor of redness and a stiff neck, but the doctor did not make anything of it.
“Adam said to Dr Diakidis that his neck and jaw were stiff and sore. Dr Diakidis then examined Adam’s neck and jaw for a period that I would estimate at approximately ten seconds and than said to Adam that there were no concerns arising.
“Adam also mentioned again to Dr Diakidis about the red patches that he was getting on his neck and jaw – and hence I saw and heard Adam tell Dr Diakidis about his red patches on two separate occasions that afternoon,” she said.
Ms Mulchorne stated that her son was ‘very sick’ on discharge, and that his condition worsened that night. He was brought back to the hospital at 3.30am.

Ciarán Tansey suggested to Coroner Patrick O’Connor a verdict of death by medical misadventure be recorded. Conor Halpin, solicitor for the hospital agreed.
In recording such a verdict, Mr O’Connor said the case was ‘very harrowing’ for Adam Mulchrone’s family. He described him as a ‘young man in the prime of his life’.
“I do hope and pray that lessons have been learned from Adam’s passing,” he added, saying he hoped that actions taken by Mayo University Hospital following Adam’s death will prevent any other families going through what the Mulchrone family have endured.
He said the family have praise for the hospital in general but a ‘great difficulty with the treatment provided to Adam’.
He said there was a ‘groundswell of evidence for a diagnosis of meningitis’ but that too long a period of time was left without the administration of an intravenous antibiotic.
Conor Halpin, on behalf of the hospital, read out a letter by the Manager of Mayo University Hospital, Catherine Donohoe, in which she extended to the Mulchrone family the hospital’s ‘sincerest condolences on the untimely death’ of Adam Mulchrone .
She said his loss was ‘immeasurable’ and his death is ‘deeply regretted by all staff and management, especially those who were involved in his care in the Emergency Department and later in ICU’.
She said they are ‘truly sorry’ for the ongoing impact the loss of Adam has had.
She said they ‘unreservedly apologise’ for the level of care Adam received and said the ‘learnings’ from Adam’s case will continue to be addressed.
Ciarán Tansey said the loss of Adam was of ‘enormous proportions’ for his family and said it was their hope that the public at large would be more aware of the signs of meningitis, namely fever, vomiting and diarrhoea, and the urgent need to attend the nearest hospital.
He said the family appreciate the post-facto investigation at the hospital and hope it means that no other family have to endure what they did.
Sympathy was extended to the Mulchrone family on their loss by all parties at the inquest.