Doctor 'contacted four times' before woman died
A doctor on call was contacted four times by staff who had concerns for a patient who later died, an inquest heard.
A verdict of medical misadventure was returned at the inquest into the death of Marian Tracy (60).
She died four days after surgery to remove her thyroid was performed on May 14, 2015. Ms Tracy, of Dodsboro Road, Lucan, Co Dublin, died from lack of oxygen to the brain due to compression of the windpipe, due to a clot following thyroidectomy surgery at St James's Hospital.
In a statement read out after the inquest, the Tracy family said they were devastated by her passing: "Marian was the heart of our family and her death has left a huge void in all our lives. We would hope that Marian's death wasn't in vain and the coroner's recommendations be put in place and hopefully prevent another family having to suffer as we have."
ENT (ear, nose and throat) registrar-on-call Dr Monica Istovan was contacted four times by hospital staff and an intern doctor relaying concerns for the patient between 6.30pm and 11.04pm on May 15, 2015. The registrar-on-call did not attend the patient in a private ward in hospital until after Mrs Tracy had suffered a respiratory arrest, Dublin Coroner's Court heard.
Concluding a two-day inquest into her death, Coroner Dr Myra Cullinane recommended that St James's Hospital and the Health Service Executive review their position of consultants operating on-call services to multiple hospitals and consider having senior on-call staff on-site within the hospital.
The coroner recommended hospital staff across all levels be enabled to contact senior staff directly and that neck swelling post thyroid surgery prompts early review by ENT staff.