Relatives of an 82-year-old man who died from MRSA at Mayo General Hospital were initially issued a death certificate that incorrectly gave multi-organ failure as the cause of death.
It was only when a daughter of John Deane, Kildaree, Crossmolina, Co Mayo, asked why MRSA had not been mentioned on the death form that the hospital issued a second one indicating the correct cause of death.
At an inquest into Mr Deane's death in Castlebar, coroner John O'Dwyer was strongly critical of the fact the death had not been notified to him by the hospital, as it is obliged to do.
He said he had been told about the death by the registrar of births, marriages and deaths. Thereafter he had spoken to a daughter of the deceased who informed him a second certificate had been issued by the hospital, so he decided to hold an inquest. Asked about the non-notification, David Richardson, for the hospital and the HSE, said the hospital had a strict protocol on the issue. The fact that this had happened was "a small blip on the radar", an "honest error".
One of the deceased's daughters, Helen Leonard, outlined how her father had broken his hip and had undergone surgery at the hospital.
When she visited more than a week later there was a sign on the door of her father's room requesting that a gown and gloves be worn when entering. When she asked about this she was informed he had MRSA.
After her father died her mother got a death certificate listing multi-organ failure as the cause of death. After inquiring why MRSA was not mentioned on the form, she got a second form listing MRSA pneumonia as the cause of death.
Bridget Hughes, consultant trauma and orthopaedic surgeon, said routine MRSA screening swabs taken on admission were negative. She said the senior house officer (SHO) on call, Dr Ahmed Kharief Omer, certified Mr Deane's death and undertook to fill out a certificate in which he gave the cause of death as multi-organ failure. He failed to notify the witness of the death or to seek advice in filling out the certificate.
Ms Hughes continued: "When I became aware of Mr Deane's death I requested that the SHO obtain a copy of the death certificate as he could not remember what he had filled in as I suspected that it had not been adequately filled out and also that he had failed to notify the coroner of the death."
She apologised that proper procedures had not been carried out and said she would try to ensure that junior staff were reappraised of what was required when filling in a death certificate.
Mr O'Dwyer said he was satisfied Mr Deane had died from MRSA, a hospital acquired infection that he developed while a patient. He hoped other families did not have to go through the same ordeal.