The family of a 34-year-old “doting” father of one who died after he spent nine hours on a chair at Cork University Hospital (CUH) before he was seen by a doctor have warned that lessons must be learned to prevent further tragedies.
Cork chemical engineer Pat Murphy died of an aortic dissection on September 3rd, 2021, at CUH having been misdiagnosed with a possible kidney stone and renal colic.
An inquest into his death at Cork Coroner’s Court heard he went to the hospital by taxi with chest pain late in the evening of September 1st, 2021 and a CT scan was ordered. His arrival at the hospital was delayed because his ambulance failed to arrive.
Triaged as a category 3 patient the PHD graduate of Lancaster University should have been seen by a doctor within an hour.
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He spent nine hours on a chair in the A&E department and his CT scan was postponed by 11 hours because one of two CT scanners on-site was broken.
The inquest heard that potentially life-saving hours were lost because of the failure to reach the appropriate diagnosis. Mr Murphy underwent emergency surgery but efforts to save his life failed.
A narrative verdict was reached in the case on Thursday, via a seven-to-one majority verdict.
The inquest heard Assistant State Pathologist Dr Margaret Bolster carried out a postmortem on Mr Murphy and found he died from a dissected aortic aneurysm with the sack around his heart filling with blood.
Dr Bolster said that Murphy suffered severe brain damage due to a lack of oxygen to the brain. The damage to the aorta was quite extensive.
Dr Bolster said that there is a “very high mortality rate” with aortic dissection.
“It is a rare and life-threatening condition. Prompt and proper diagnosis and treatment is vital.”
She said that aortic dissection is a life-threatening condition with a mortality rate which increases by 1 to 2 per cent an hour which requires prompt and proper diagnosis and treatment. Dr Bolster added that aortic dissection is rare in a person under the age of 40.
Dr Frank Leader, head of education and training at CUH emergency department, was asked why it took nine hours for Murphy to be seen by a doctor given that he was triaged as a category 3 patient and ideally would have been seen within an hour.
Dr Leader said that it was “extraordinarily difficult” to meet that timeframe. He added that the Murphy case was discussed at length at their monthly clinical risk meeting. He said that lessons were digested and disseminated to the department at large.
Other improvements implemented at CUH include special orientation training for doctors on aortic dissection, the hiring of more senior doctors and increased case discussions, an expanded email reference platform and the allocating of consultants to specific areas.
Coroner Philip Comyn extended his heartfelt condolences to the family of the deceased following their “out of the blue” family tragedy. He said that certain learnings would be made following their notices.
Murphy is survived by his wife Keerti Krishnan Murphy and their young son, as well as his parents Willie and Noreen and his siblings Sinead, Yvonne, Suzanne and Tracy.
Keerti and Yvonne Murphy have indicated that vital lessons need to be learned following the death to prevent future unnecessary fatalities of this type.
CUH management has apologised to the Murphy family for failings in the care of their loved one.
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