The family of a Dublin woman who died after being discharged from St James's Hospital in the city last year is considering suing the hospital. A consultant admitted at an inquest yesterday that there had been an error of judgment in sending her home.
The inquest issued a verdict of death by misadventure in the case of Mrs Josephine Hanbury (76), at Dublin City Coroner's Court.
The court heard that Mrs Hanbury, of Dolphin House, Rialto, was brought to St James's Hospital's Accident and Emergency department by ambulance on the evening of Saturday, September 23rd, last year, suffering severe abdominal pain.
Mr Terence Boyle, consultant general surgeon who was on call at the hospital that weekend, told the court that Mrs Hanbury was seen half-an-hour after she arrived but was too distressed to give a full history. She was also vomiting blood.
She was referred for surgical review.
The surgical team referred her for a medical assessment following which she was referred back for review by surgical staff.
"Mrs Hanbury was subsequently seen by Dr Grainne McAuley, an SHO attached to the General Surgical Department," said Mr Boyle. This was at 2.30 a.m. on September 24th.
She discussed Mrs Hanbury's case with a more senior colleague, Mr Narayansamy Ravi.
"Unfortunately, he was detained in the operating room and not immediately available to assess the patient," said Mr Boyle. They judged she did not require surgery and she was referred back to the medical team.
Mrs Hanbury was discharged at 3.30 a.m. but returned that night at 9 p.m. with increased pain. She was seen at 10 p.m. and tests indicated acute pancreatitis, or an inflamed pancreas.
Mr Boyle first saw Mrs Hanbury in the A&E observation ward during his Monday-morning rounds. He had her transferred immediately to the High Dependency Unit where she was managed as an intensive care patient.
That evening he noted her "acute deterioration" and arranged a CT scan to see if surgery was necessary. She was then "managed conservatively" through the night to see if she would settle.
She deteriorated further, said Mr Boyle, and he felt "she would certainly die if no intervention were undertaken".
Exploratory surgery found a perforated ulcer on the duodenum, and this was treated. Immediately after surgery her progress was "quite promising'. However, overnight she grew critically ill and despite medical attention died at 4.45 p.m. on Wednesday, September 27th.
A post-mortem found that Mrs Hanbury died of acute peritonitis, or an inflammation/infection of the abdominal cavity, caused by a perforated duodenal ulcer.
The initial decision to send Mrs Hanbury home in the early hours of Sunday morning was an error of judgment, said Mr Boyle. However, it was difficult if not impossible to say whether Mrs Hanbury would have survived if she had been admitted 24 hours earlier, he said.
The City Coroner, Dr Brian Farrell, accepted the pathologist's assessment that Mrs Hanbury died from acute peritonitis and said that taking all the conditions into account a verdict of death by misadventure was the most appropriate.
He noted the hospital's introduction, following Mrs Hanbury's death, of a policy that no patient in a similar situation should be discharged without review by a senior surgeon.
Mr Thomas Hanbury, one of Mrs Hanbury's family of three sons and one daughter, said the family was happy with Dr Farrell's verdict but said the health service had failed them and their mother.
"It doesn't end here. We will be discussing where we go with our legal team," he added.
