A CORONER has hit out at a series of failures at Galway University Hospital after an elderly man died from a large aneurysm that was not acted on for more than two years after it was detected.
John Joseph Ryder (71) from Aughlora, Tuam, Co Galway, died from an abdominal aneurysm that was first detected at University Hospital Galway in May 2009 but was not made known to the patient or his GP and not followed up on.
Mr Ryder had several cardiology reviews in the years following his discharge and attended the hospital up to six times, but the aneurysm was never referenced or treated.
He died on November 25, 2011, as a result of the aneurysm.
Recording a verdict of medical misadventure, Galway West Coroner Dr Ciaran MacLoughlin criticised the "failure in communication practices and also a failure in letter writing to the GP".
The inquest heard that by the time of his death, the aneurysm had increased in size from 6cm to 8cm and could rupture at any stage.
The failure to properly record the condition in Mr Ryder's notes or subsequently act on the potentially life-threatening condition was described as a "systems failure" by Dr MacLoughlin.
"Had it been acted upon he may very well not have died," he said.
The coroner questioned why doctors were not given the full medical history by junior staff during ward rounds.
"In this case, the very simple system which has worked for generations of doctors did not occur," he said.
He added that the most important person who should have been told of the condition was Mr Ryder's GP.
Nobody was aware until the fatal rupture of the aneurysm.
Earlier, a consultant cardiologist apologised to the Ryder family.
Dr Jim Crowley, who first detected the aneurysm on May 5, 2009, apologised for failing to put in place a follow-up plan for Mr Ryder.
On Mr Ryder's admission to hospital in 2009 he was critically ill from encephalitis, an extremely rare disorder which causes an inflammation of the brain. An ultrasound discovered the presence of the aneurysm.
Dr Crowley told the inquest this was not a risk to him at that time and Mr Ryder would not have been well enough for treatment at the time.
Mr Ryder's daughter Caroline Gordon told the inquest that the family had never been told of their father's aneurysm.
"The first I heard of it was on the day he died," she said.