‘Systems failure’ led to 26-year-old’s death, inquest hears

The mother of a 26-year-old who died after what a coroner described as a hospital “systems failure” has said she was appalled by the way her son was treated.

Angela McCloskey said her son John Paul did not receive the treatment he required when he was admitted to Letterkenny General Hospital on October 12th, 2016, suffering from diarrhoea and vomiting.

I wonder did our Lord suffer as much on the cross as I am suffering right now?

He was to be transferred to the care of a gastroenterologist for a possible bowel obstruction but there was a breakdown in communications. In a statement presented to the inquest the gastroenterologist said he was never made aware of the case. He was going away to a conference two days later and was only made aware of the case when he came back several days later.

Mr McCloskey, from Hillhead, Buncrana, Co Donegal, continued to deteriorate and died on November 22nd.

Mrs McCloskey said one of the final things her son said to her was: “I don’t know what’s happening to me, Mummy. I wonder did our Lord suffer as much on the cross as I am suffering right now?”

“I said to John I will see you tomorrow, he blanked me and stared at the wall. He never spoke a word from that night until he died. He was a corpse.”

Forgave all

But Mrs McCloskey said she forgave all involved and just hoped that hospital systems would be put in place to ensure another family did not have to go through what they have endured.

“I want to forgive all concerned. My poor John will rest in peace now,” she said.

Galway West coroner Dr Ciaran MacLoughlin said that when a person is admitted to hospital the patient has a reasonable expectation that somebody will take overall charge of their care. But he said it was clear that in the case of Mr McCloskey this did not happen.

An inquest into his death in Galway on Thursday heard he underwent surgery but lost consciousness from septic shock after suffering a perforated bowel. He was placed on a ventilator and later transferred to Galway University Hospital where he died.

“I didn’t know if it was necessary for him to go to Galway. But we were all together when he died. It was a blessing in disguise,” added Mrs McCloskey.

Dr MacLoughlin, after hearing evidence at the day-long inquest, said there had been a systems failure in the hospital.

He said it was reasonable to ensure public confidence in the system that patients, when admitted to hospital, have a nominated consultant. “They have overall responsibility over treatment of the patient, and to ensure any consultant requested, if they have input, it should be documented.

‘Ward sister’

“The old-type ward sister, she had control of ward and she surveyed it. She would have ensured a patient was seen by a consultant and a patient would know their consultant. Under modern systems that is delegated to a number of people or no one at all. There needs to be someone in charge,” said Dr MacLoughlin.

He said that the deceased had difficulties in his life but should have expected to be treated when he presented at hospital. “The much-loved son and brother, he was, as his mother said, a young boy and man who struggled as life wasn’t kind on occasion. He suffered from dyslexia and didn’t perform academically, he didn’t do exams and didn’t hold down a job.”

He found cause of death to be due to hypoxic brain injury due to perforation of a small bowel caused by Crohn’s disease. “This was as a result of a systems failure and one can only say this was a result of medical misadventure,” added Dr MacLoughlin, who extended his sympathy to the family of the deceased.

Counsel for the HSE Sasha Gayer offered condolences to the family.