The Health Service Executive (HSE) has apologised to the family of a 67-year-old man for a “deviation in procedure” which triggered his death at Mayo University Hospital.
Dr Simon Mills SC, tendered a “sincere apology and condolences” to Geraldine Best, widow of Martin Best, and her family, at an inquest hearing in Swinford on Friday.
Dr Mills made the apology after the coroner for Mayo, Pat O’Connor, returned a verdict of misadventure at a hearing into the death of Martin Best of Childers Heights, Ballina, at the Mayo hospital on January 12th, 2019.
Mr O’Connor was asked to conduct an inquest into the death by the Attorney General at the request of the Best family through their legal representative, Johan Verbruggen of Callan Tansey & Co.
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Evidence was given at a previous hearing that Mr Best was admitted to the hospital on January 1st, 2019. He was receiving treatment for advanced chronic obstructive airway disease (emphysema) and lower respiratory tract infection. The inquest heard policy procedures for the removal of a central venous catheter (CVC) line were not followed in his case.
The coroner was told Mr Best was allowed to sit up from the procedure sooner than recommended. Patients are advised to remain in a lying, flat position for approximately five minutes following the removal of CVC lines.
Also it is stipulated that CVC lines should be removed with two people present but there was only one, Dr Muhammad Iqbal, medical registrar, in attendance when the procedure was carried out.
In a statement read to a previous hearing, Dr Iqbal said he “accepts with the benefit of hindsight that allowing Mr Best to sit up (in a chair beside the bed) was a deviation from accepted protocol”.
The medical cause of Mr Best’s death was outlined by a pathologist as “arrhythmia secondary to dilated cardiomyopathy, pneumonia, chronic obstructive airway disease and ulcerative colitis”.
The coroner said on Friday in his view the removal of the CVC line on January 8th, 2019, was the trigger for the deterioration in Mr Best’s medical condition.
He said the medical staff had been “confused, perplexed and puzzled” by Mr Best’s reaction to the removal of the CVC line.
“In my view, the trigger, the catalyst for the death was the removal of the CVC line”, the coroner continued.
Nine members of the Best family were in the public gallery for the hearing. Some broke down on hearing the verdict.
Afterwards, Mr Best’s widow, Geraldine, speaking on behalf of the family, said: “Martin was let down twice. He was put in danger’s way by being allowed to sit up so soon after having the central line taken out of his neck.
“Then, when recording his death, the hospital made no mention of this serious incident . . . the least he deserved, and the least every patient deserves is accurate recording how they died.
“How many more deaths have occurred in unnatural circumstance, which have not been properly recorded.”
Mr Verbruggen, solicitor for the family, said that due to the death not being accurately recorded the family were forced to write to the coroner and the Attorney General to demand an inquest.
“That should not have had to happen. It has prolonged the family suffering and the ordeal of getting answers and closure.”