A coroner noted the “extremely challenging” work environment facing hospital staff as she recorded a verdict of misadventure at an inquest into the death of a man who spent 11 hours waiting to be seen by a doctor in Tallaght University Hospital’s emergency department (ED).
Gary Crowley (35), from Killinarden, Tallaght, died early on September 21st, 2021 as a result of metabolic ketoacidosis and an upper gastrointestinal bleed, Dublin District Coroner’s Court heard on Wednesday.
Discrepancies in documentation outlining the Manchester Triage System available to nursing staff in the ED meant that Mr Crowley was triaged as a category 3 rather than a category 2 patient. Category 2 patients should be seen by a clinician within 10 minutes of triage, while category 3 patient should be seen within one hour.
Mr Crowley presented at the ED after 12.10pm on September 20th and had to wait until after 2pm to be triaged by nurse Fiona Rogan.
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Ms Rogan told the court the ED was “extremely short-staffed” on the day, with just two nurses working the triage area when there should have been four. She said this caused “significant delays” to the triage process and that 111 patients presented at the ED over the course of her shift.
She said Mr Crowley presented complaining of persistent vomiting over four days and having aches and pains all over his body. The court heard Mr Crowley, who suffered with alcohol dependency and psychological issues, had spent the three days before presenting at the hospital bingeing on alcohol. He suffered with deep vein thrombosis – blood clotting – and was on anticoagulant medication.
Nurse Carol Greene said she was alerted at 9.25pm by reception staff saying that Mr Crowley was lying on the floor in the waiting room. He told Ms Greene he had “pain everywhere” and she discovered he had an elevated heart rate of 141 beats per minute.
Mr Crowley was moved to a sub-waiting area in the ED and was seen at 11.05pm by senior house officer Dr Gavin Sedgwick, who prescribed IV fluids.
Dr Aileen McCabe, a consultant in emergency medicine, later said this was the correct treatment for Mr Crowley as he was “clearly dehydrated” and had suffered an acute kidney injury. “The management was correct, but unfortunately it was delayed.”
Nurse Danilo Garin said he was about to administer the prescribed medication to Mr Crowley at around 1am, but the patient became distressed and then unresponsive. With Mr Crowley in cardiac arrest, he commenced CPR immediately and called for assistance.
Mr Crowley’s care was handed over to a resuscitation team, but his condition did not improve and he was pronounced dead at 2.45am.
Dr McCabe said staffing levels were “inadequate” for the volume of patients that presented at the ED that day and noted a lack of clinical space available to treat patients. She said capacity remains inadequate in Tallaght’s ED, with the hospital dealing with greater volumes of patients than during the Covid-19 pandemic.
She outlined policy changes aimed at improving care for ED patients implemented following Mr Crowley’s death and said she was sorry that Mr Crowley had to wait so long.
Claire Crowley, Mr Crowley’s sister, said her brother’s death had “decimated” the family and devastated her father’s physical and mental health. In her deposition, Ms Crowley said her brother complained of feeling “ignored” by nurses in the ED.
“If we can get some sort of justice from this for Gary, it would be to prevent something like this happening to another person,” she said.
Coroner Dr Clare Keane returned a verdict of misadventure. She expressed sympathy to the deceased’s family, and acknowledged the “extremely challenging” work environment faced by hospital staff which was “outside of your own control”.
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