Parents of tragic teen had pleaded for visit by heart consultant
Published 11/04/2014 | 02:30
A TEENAGER who died from a ruptured heart was in hospital for a week before a consultant cardiologist examined him, an inquest heard.
Daniel Clarke (17) from Calry, Co Sligo, was admitted to Galway University Hospital (GUH) with a suspected adverse reaction to medication.
However, his parents told Dublin Coroner's Court they believed he was in heart failure and they pleaded for him to be seen by a consultant cardiologist.
Daniel died at the Mater Hospital on December 19, 2012, after going into cardiac arrest shortly before an emergency heart operation. At a post-mortem, it was found that a tendon in his heart's mitral valve had ruptured, leading to his death.
The teenager was born with congenital heart disease and underwent a successful repair operation at 12 months old. His father Stephen Clarke said that his son had lived a "full, healthy life" and was involved in outdoor activities including cycling in 100km road races.
He was admitted to GUH on December 10, 2012, suffering an acute liver injury which doctors believed could be related to anti-psychotic medication Olanzapine. He had been taking it following a psychotic episode brought on by steroids prescribed to treat asthma. Mr Clarke said in the days before his admission, Daniel seemed physically "much weaker".
Following admission, Daniel's parents became concerned that he was not seen by a cardiologist within 24 hours. They raised their concerns a number of times with Daniel's doctors. His mother Sheila Clarke said she pleaded with staff to have Daniel seen by a cardiologist on the day after his admission to the hospital.
Consultant physician Dr Andrea Holmes said that on the third day of admission she spoke to the cardiac registrar requesting a cardiac consult and was told to arrange an echo cardiogram first. This was carried out two days later on Friday, December 14. Dr Holmes again requested a cardiac consult on the same day. Daniel's condition deteriorated during the weekend and on Monday Dr Holmes again called for a cardiac consult. The teenager was seen by consultant cardiologist Dr Pat Nash.
Dr Nash said the consult had been listed as "routine" on the hospital's referral system and he could find no record of any earlier referral to cardiology. He said the liver failure was "disproportionate" to the signs of heart failure he saw. The results of the echo cardiogram showed severe mitral regurgitation and Dr Nash requested the results of Daniel's last echo report from Crumlin Hospital to establish if there had been any major change.
However, the following day Daniel was transferred to St Vincent's liver unit and was sent to the Mater Hospital later that evening for emergency heart surgery but died in the early hours of December 19 before the operation could take place.
Daniel's death was a "very tragic and complicated case" coroner Dr Brian Farrell said, and it was clear there had been a communication breakdown.
He returned a narrative verdict and recommended, without prejudice, that GUH reviews the process for requesting in-house consultant consultations and other matters raised at the inquest.