Inquest hears CT scan went unread for three days

Narrative verdict recorded at inquest into death of mother of 13 at Mayo General Hospital

Anton McNulty

An inquest into the death of a 69-year-old woman heard that there were delays in diagnosing the perforation of her bowel and that results of her CT scan were left unread for three days in Mayo General Hospital.
Eileen Maloney of Glengad, Pollathomas, Ballina, died from multiple organ failure on February 17, 2009, after she failed to recover from an operation undertaken five days earlier.
Mrs Maloney, a mother of 13, was admitted to Mayo General Hospital on February 1, and tests showed that she had cancerous tumours on the liver and that the disease had also spread to her bowel.
An independent review of her care prior to her death indicated that there had been delays in identifying a large bowel obstruction and the perforation of her bowel.
Professor Michael Keighley, who compiled the report, explained that if the delays had not occurred, surgery would have take place at an earlier date. If this had occurred, he said, she would have survived the surgery and lived for another four to six months.
Professor Kevin Barry, consultant surgeon, told the inquest that over 60 percent of Mrs Maloney’s liver had been taken over by the tumour, and that he had concerns about performing an operation on her. When he discussed the risks with her, he said she wished for the operation.
Prof Barry said her liver and kidney were compromised and that any surgery would be of a palliative nature. He expected she would not have survived for more than four weeks if she had survived the surgery.
The inquest, held in Castlebar on Tuesday, heard that Mrs Maloney had a CT scan on the afternoon of Friday, February 6, but the scan was not read until Monday, February 9. The scan showed a high-grade large bowel obstruction, and Prof Keighley claimed that if it had been read earlier, surgery could have taken place over the weekend.
Mrs Maloney also suffered a perforation of the bowel on February 11 after complaining of severe pain. Despite a chest x-ray showing free air below the diaphragm – indicating a tear – the information was dismissed by a member of Prof Barry’s team, who said it was a a breast shadow.
Mr John O’Dwyer, Coronor for South Mayo informed the jury that the verdict options they could record were death by natural causes, a narrative verdict in accordance with the cause of death or a verdict of misadventure.
The jury returned a narrative verdict in accordance with the cause of death, which was was multi-organ failure in the context of bowel perforation and metastatic disease.