A coroner has returned a verdict of medical misadventure following an inquest into the death of a student who was admitted to Sligo University Hospital (SUH) after collapsing and vomiting with a sudden severe headache in a fast-food restaurant.
A core issue at the inquest into the death of 19-year-old Lisa Niland concerned a delay at SUH in carrying out an emergency CT scan which disclosed a bleed on the brain.
Ms Niland from Drimbane, Curry, Co Sligo, was admitted to the hospital about 9.30pm on 17th January, and the scan was carried out about 10.05am the following morning.
She suffered cardiac arrests and was effectively brain-dead when she arrived at Beaumont Hospital in Dublin by helicopter about 1.30pm that same day. She was pronounced dead on January 20th and the cause of her death was a catastrophic bleed to her brain.
On Tuesday, Dublin City Corner Myra Cullinane found Ms Niland died as a result of a bleed to the brain.
She noted several recommendations in an internal review, carried out after Ms Niland’s death, concerning the carrying out of emergency CT scans have or are being implemented at SUH and other similar hospitals.
She made an additional recommendation for “serious” review of the practice of only having consultants involved in considering whether to carry out CT scans, saying that could cause difficulties for patients.
After the verdict, Amy Niland, Lisa’s younger sister, flanked by her parents Angela and Gerry, said the family’s life has been “shattered forever” as a result of Lisa’s death.
“A most special person has been taken from us. My sister was a beautiful, kind, witty young woman who touched so many hearts. Her smile and presence lit up the room, she had a gentleness that you so rarely find, she saw the best in everything and everyone. I always looked up to Lisa in everything I did and I will continue to but for now I hope she’s looking down until we’re together again.”
The family’s solicitor, Damien Tansey, said the verdict marked the end of an “enormous” family tragedy.
Ms Niland was admitted to SUH with “classic” signs of a brain haemorrhage and the first nurse who assessed her formed the view she needed a CT scan but that was not done until 10.05am the following day, he said.
A neurosurgeon at Beaumont who operated on Ms Niland had indicated this case was time sensitive and it was absolutely essential to make an assessment about the nature of her injuries and get her to Beaumont as soon as possible. Unfortunately, valuable time was lost, Mr Tansey said.
The inquest into Ms Niland’s death opened in March 2019 but was adjourned for further evidence.
After evidence concluded on Tuesday, Mr Tansey urged the coroner to return a verdict of medical misadventure arising from delay in carrying out a CT scan on Ms Niland.
Declan Buckley SC, for SUH, argued for a narrative verdict, saying the evidence did not establish that delay was a causative factor in Ms Niland’s death.
‘Hugely’ time sensitive
In her decision, the coroner said there was early consideration at SUH of the performance of a CT scan and various investigations were conducted.
Contact was made with consultant staff about 2.15am, in line with a requirement that decisions on emergency scans be made by consultants, and it was decided a CT scan should be done in the morning. Ms Niland was later reviewed by a registrar about 3.40am who requested a CT scan.
She was observed as having acutely deteriorated about 8.30am and a CT scan carried out at 10am revealed a bleed. She was removed by medical helicopter to Beaumont about 1.30pm on 18th January.
The coroner said she had earlier intended to record a narrative verdict, a neutral account of the circumstances, but was prevailed upon to hear evidence on Tuesday from Donncha O’Brien, a neurosurgeon at Beaumont.
Mr O’Brien had told the inquest the “hugely complicating” factor in Ms Niland’s case was that she had hydrocephalus as well as a bleed. Her condition was “hugely” time sensitive and the quicker it was dealt with, the better the outcome.
He agreed he had told Ms Niland’s father, Gerry, that had she arrived at Beaumont earlier, there might have been a better outcome. The inquest heard he had tears in his eyes when discussing Ms Niland’s situation with her father on 18th January.
Mr O’Brien, the inquest heard, was involved in 2010/11 in preparing guidelines for hospitals across the country for dealing with sudden onset “thunderclap” headaches, which included that CT scans should be carried out within an hour of such admissions. The guidelines were sent by the HSE to the CEOs of all hospitals, he said.
The coroner said, following Mr O’Brien’s evidence, she was recording the “equally neutral” verdict of medical misadventure, the unintended outcome of an action or omission, which does not impute blame or liability.
She noted a number of changes had been put in place in SUH since Ms Niland’s tragic death, including an on-site radiographer and a senior doctor available on a 24 hour basis in the Emergency Department.
Emergency medicine consultant Fergal Hickey, who was among those who dealt with Ms Niland on the night of 17th/18th January, previously told the inquest that decisions made by him, including for a CT scan to be carried out the following morning, were made in good faith and the situation he found himself in, including being told by another doctor at 2.15am there were no neurological signs present at that time. Another factor was, if he had called in a radiographer in the middle of the night, that radiographer would not have been available to the hospital the following day, Mr Hickey said.
