A verdict of medical misadventure has been recorded at the inquest of a Limerick woman who died hours after she was discharged from University Hospital Limerick.
Eve Cleary (21), from Corbally, Limerick, died in the early hours of July 21st, 2019, after presenting at UHL while suffering cardiac arrest and with a swollen leg, the inquest held at Limerick Coroner’s Court heard.
The coroner has made a recommendation that HSE guidelines around assessing patients for risk of blood clots, particularly deep vein thrombosis, be followed by staff at the hospital “as much as they can”.
Ms Cleary initially presented at UHL two days previously, July 19th, with a swollen right leg after she had suffered a fall in Limerick city.
She spent 17 hours on a trolley in the hospital’s overcrowded Emergency Department without a pillow or a blanket.
Her trolley was one of dozens more cramped together in a foul smelling corridor of the ED, where, on the day, a “record” number of patients were waiting for beds, the inquest heard.
Ms Cleary’s parents said that when they visited their daughter in the hospital they found her on a trolley near a sink that had been used as a toilet. Her mother Melanie Sheehan Cleary said “the smell of urine caught in your breath and made you cough”.
Ms Cleary had presented at the hospital on July 19th with a number of risk factors for thrombosis and blood clots, including being on a contraceptive pill that specifically increased the risk of blood clotting; was a smoker; was overweight; and there was a history of blood clots in her family.
Skeletal staff
She spent the night on the trolley in the overcrowded ED and was given a bed on a ward the following day. Her patient files appeared to be missing on the ward, and the ward nurses were not fully aware of why she was there, the inquest heard.
The hospital was operating with a skeletal staff and, as it was the weekend, there were no staff to operate the hospital’s ultrasound equipment. A blood test and an ultrasound scan are the two main methods of diagnosing a blood clot, it was heard.
At this point, Ms Cleary’s mother temporarily left the inquest in tears saying, “So, she would have died anyway...disgrace”.
Ms Cleary was not assessed for risk of blood clots and she was never seen by a consultant, although a report of a CT scan of her leg, which found no fracture or abnormalities, was read by the hospital’s on-call consultant orthopaedic doctor.
Ms Cleary was discharged with a suspected soft tissue fracture.
Her mother wept as she recalled how her daughter’s leg had swelled to “three and half times” its normal size while in the hospital, and that it turned dark red “like the colour of a Christmas ham”.
A WhatsApp text message found on Ms Cleary’s phone, which she had sent to a work colleague, indicated that she believed those involved in her care were considering she may have had a blood clot.
However the inquest heard that at no stage did any of the doctors involved in Ms Cleary’s care ever suspect at any stage that she was suffering from a clot.
Cardiac arrest
Four hours after she was discharged from UHL, on a wheelchair, as she could not walk with the pain, Ms Cleary went into cardiac arrest at her family home.
Her father Barry Cleary fought back tears as he described how he desperately tried to keep his daughter alive by performing chest compressions and CPR on her.
She was taken by ambulance to UHL where she was pronounced dead at 1.50am on July 21st.
A postmortem found the cause of death was due to cardiac arrest due to extensive bilateral thrombo-embolisaiton or clots that had blocked her lungs.
The clots were most likely due to recent trauma, said UHL Pathologist, Dr Teresa Laszlo, who conducted the autopsy, but she could not say when exactly the clots had occurred.
Counsel for the Cleary family, Doireann O’Mahony BL, said it was “insulting” to Eve’s family that no formal apology had been offered to them surrounding her death.
Coroner John McNamara returned a verdict of medical misadventure.
He said there were “missed opportunities” in Ms Cleary’s case, but stressed this was not to fault anyone involved in her care.
Mr McNamara said he also accepted Ms Cleary’s parents’ “harrowing evidence” about what they had witnessed in the overcrowded hospital.
Ms Cleary’s parents said afterwards that their daughter’s death could have been prevented and that she had been “failed” by those tasked with her care.
Mr Cleary likened the emergency department to a “cattle mart” due to the high numbers patients on trolleys when his daughter was there.