AN ELDERLY man who had a heart attack in a hospital died after a failure to transfer him to another, despite an ambulance being available.
Eneas McDonnell (74), of Leenane, Co Galway, suffered the attack at Mayo General Hospital in Castlebar last August 17.
No cardiac facilities are available there, and he was awaiting transfer to Galway. However, a mix-up in the use of codewords for emergency ambulances left him waiting almost two hours and he suffered a fatal attack.
During his inquest this week, it emerged that the failure to free up an ambulance happened after the clinical nurse manager failed to use the correct codeword. The system had only been in place since the previous month.
As a result, the call to the National Ambulance Service was not categorised as an emergency, despite the nurse manager describing it as such.
Had she used the trigger word, Code Stemi, an ambulance would have been sent straight to the hospital. It also emerged that there was an ambulance at the Castlebar base that night which was on call.
Mr McDonnell was brought to the hospital at 8.35pm last August 17, and tests showed he was having a heart attack.
However, as there is no cardiac facility at Mayo General Hospital, doctors were advised to transfer him immediately to Galway University Hospital.
When attempts were made to secure an ambulance at 9.05pm, hospital staff were told none would be available until 11pm. This was despite the fact that two ambulances were stationed outside Mayo General at the time.
The clinical nurse manager was told the ambulances could not be used as they were "not clear", according to the 'Mayo Advertiser'.
On hearing of the delay, medical staff opted to thrombolyse the patient, breaking down potential blood clots while they awaited an ambulance.
A private ambulance was also called and was en route to the hospital when Mr McDonnell suffered a heart attack at 9.40pm. Despite resuscitation attempts, he was pronounced dead at 10.20pm.
It also emerged that at 9.23pm the ambulance dispatcher told medical staff an ambulance was on the way, but was informed that he was having a drug administered and a private ambulance was coming.
An internal review has since been carried out by the National Ambulance Service, and all such hospital transfers are treated as emergency cases.
Coroner for south Mayo John O'Dwyer praised the attempts by hospital staff to save Mr McDonnell, but raised concerns about the delays patients faced in emergency situations.
Fianna Fail TD Dara Calleary said that while he accepted cardiac facilities could not be set up in every regional hospital, he insisted an emergency facility was necessary in Mayo.
"Situations like this should not happen," he said. "We need an emergency facility in place in Mayo General."