A family declared they hope lives will be saved from lessons learned from their father’s death.
The death of their dad from a rupture in a major artery was a result of “medical misadventure,” a jury declared at his inquest today.
Timothy Fleming (69), an Irishman living in England, died after a tear in the lining of his aorta led to a rupture of the artery on February 6, 2015.
Kevin Power, a solicitor for Tallaght Hospital offered his family the “sincere regret” of the hospital for aspects of the care provided to him after he was admitted suffering from severe pain in his abdomen on the day before his death.
His four adult children, who were present at the inquest represented by solicitor Roger Murray, accepted an invitation from the hospital yesterday to meet with staff to explore ways of improving ways of caring for patients with similar conditions.
The two day inquest at Dublin Coroner’s Court heard that the father-of-four, a native of Fossa, Killarney, was living in Middlesex and had travelled to Dublin for a meeting in Tallaght. He became unwell with a severe pain in his abdomen and was taken by ambulance to Tallaght hospital.
The court heard he was seen by a number of doctors during the course of the afternoon and evening and received morphine for the pain.
A number of doctors gave evidence that a number of possible causes of the pain were explored but there was no definite diagnosis on that date. An “aortic dissection” which is a tear within the lining of the aorta and a very rare condition, was just one of many possible causes considered.
But he was discharged from the hospital at 2.30am after doctors held telephone conversations with on-call surgical registrar Dr Donal O’Connor. Senior house doctor Alaa Mustafa said the surgeon told him by telephone that, as it appeared to be a case of gastritis, Mr Fleming should be discharged to leave the hospital and return home to the UK where he could receive follow up treatment.
Mr Fleming suffered severe pain shortly after leaving the hospital and was re-admitted at 4am. An ultra-sound showed signs of a tear within the aorta.
Conflicting recollections were given to the inquest by doctors who attended him and the surgeon Donal O’Connor.
Dr O’Connor arrived at the hospital shortly before 6am. An X-ray showed evidence of a tear within the aorta. Mr Fleming’s vital signs dramatically dis-improved when he was undergoing a CT scan and he had to be resusitated.
Specialists at Tallaght did not have the skills to carry out a very specialised surgical procedure and he was transferred to St James for the surgery with a garda escort.
When he was administered an anesthetic at St James's Hospital for the surgery, he suffered a sudden rupture of the aorta and he suffered a systolic cardiac arrest. His aorta was quickly repaired while surgeons tried to resuscitate him but he died on the operating table.
The jury confirmed death was the result of the tear and subsequent rupture of the aorta. They returned a verdict of medical misadventure, which does not apportion blame but states that death was the unintended outcome of actions taken. They recommended improvements in written communications between doctors regarding what they believe is wrong with patients, that surgical staff must be retained within hospitals on a 24 hours basis to approve scans and treatments, and that all staff be made more aware of the rare aortic dissection condition.
Caroline Fleming said afterwards the family hoped other lives will be saved by the lessons learned from their father’s death.
Mr Fleming's daughter Catherine addressed a conference of cardio-thoracic surgeons from Britain and Ireland in Belfast in March about her father's treatment and the experience of her family.
She has become active in the Heart Research UK charity which is funding masterclasses for surgeons to undertake specialised surgery for the condition which claimed her father's life.
The husband of the late Malak Thawley, who died at the National Maternity Hospital in Dublin while undergoing surgery for ectopic pregnancy, said he hopes lessons will be learned from her death after it emerged doctors had to ask a local pub for ice to save her life.