Medical staff should have intervened sooner and more effectively as the condition of a woman who died at St James’s Hospital in Dublin two years ago deteriorated, an internal investigation has found.
Marian Tracy (60) of Dodsboro Road, Lucan, Co Dublin, died at the hospital on May 18th, 2015. She had undergone a thyroidectomy, an operation to remove her thyroid gland which was overactive.
The operation was performed four days earlier and was without incident. However, the following day, Mrs Tracy experienced swelling on her neck and consequent difficulty breathing.
Throughout the day as her condition deteriorated, an intern ear, nose and throat (ENT) doctor on duty liaised by telephone with an ENT consultant outside the hospital from whom he sought guidance and sent photographs of Mrs Tracy’s neck to.
The St James’s Hospital internal report into what happened includes a timeline of events. It shows that between 9.20pm and 11.23pm on May 15th, while “extremely distressed” because of her breathing difficulty from the swelling, Mrs Tracy suffered a cardiac arrest, followed by another at 11.26pm as doctors and nurses fought to save her.
She was pronounced dead at 5pm on May 18th. Her family had remained at her bedside and gave permission for her organs to be donated.
Apology
The internal review of what happened, and recommendations as to how a recurrence could be prevented, begins with an apology to Mrs Tracy’s family.
The hospital says it acknowledges that what happened “was devastating and has had a profound effect on her family”.
The review, which refers to Mrs Tracy throughout as Patient X, says that when her neck swelled from mid-afternoon to early evening on the day after her surgery, “this clinical situation should have prompted review by a senior (experienced) ENT surgeon”.
“Opportunities appear to have been missed for the timely escalation of the patient’s care to a doctor experienced in the surgical management of complications in patients after thyroidectomy and/or the recognition and management of potential airway compromise,” it says.
“Contributory factors included apparently poor insight into the potential for progression of the patient’s neck swelling and the need to call for help early based on an appreciation of this clinical risk.
“Nursing staff reported to an on-call doctors that they thought Patient X had a neck haematoma. On-site examination of the patient by an experienced ENT surgeon would have facilitated a more timely surgical intervention and a better patient outcome.”
The report says that expressions of concern by both Mrs Tracy and her family “did not result in an effective response, despite the best intentions of all the clinical staff involved”.
It adds: “The fact that senior ENT surgeons were not more responsive in her management is a concern to the investigators.”
Five recommendations
The investigators, Dr Carl Fagan, a consult anaesthetist, and Una Healy, a clinical safety and risk manager, made five recommendations.
They include that St James’s must ensure that “at all times doctors and nurses have the competencies relevant to their area of responsibility and expertise to recognise and appropriately respond to acute life-threatening emergencies in a timely way and to engage senior medical staff early based on clinical risk assessment of a patient’s condition”.
They say clinical staff “should be empowered to escalate concerns to the most senior staff on-call at any time” and that a formal process is developed to ensure continuity of care during clinical handover between medical, surgical and nursing staff.
In July, a verdict of medical misadventure was returned at the inquest into the death of Ms Tracy. Coroner Dr Myra Cullinane recommended that St James's Hospital and the HSE review their policy of consultants operating on-call services for multiple hospitals and consider having senior on-call staff on-site at the hospitals. She also recommended that hospital staff across all levels be enabled to contact senior staff directly and that neck swelling post-thyroid surgery prompt early review by ENT staff.
In a statement, the Tracy family said they were devastated by Marian’s loss, and that they hoped “Marian’s death wasn’t in vain and (that) the coroner’s recommendations be put in place and hopefully prevent another family having to suffer”.
