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Family 'never got to say goodbye' as jugular cut in surgery killed mum

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Geraldine O’Brien said her family felt betrayed by the ‘cold and cruel’ response to the death of Teresa Lyons

Geraldine O’Brien said her family felt betrayed by the ‘cold and cruel’ response to the death of Teresa Lyons

Geraldine O’Brien said her family felt betrayed by the ‘cold and cruel’ response to the death of Teresa Lyons

The HSE has offered its "sincerest apologies" to the family of a woman who died after her jugular vein was torn in routine surgery.

Teresa Lyons's grieving daughter Geraldine O'Brien told her inquest yesterday that, on the day her mother died, her family was forced to leave her alone in a "hugely overcrowded" Emergency Department at University Hospital Limerick.

The family was told by staff to leave the seriously ill 76-year-old as there was only room for patients, Ms O'Brien said.

Guilty

A verdict of medical misadventure was returned at the inquest, held at Limerick Coroners Court.

Teresa Lyons, of Granville Park, Limerick, who had a history of diabetes, went to the hospital on December 29, 2016, with vomiting and diarrhoea.

She died eight hours later during a routine surgical procedure after her condition worsened, her inquest heard.

Reading from a victim impact statement, Ms O'Brien said she and her siblings feel "guilty" because they never got a chance to say goodbye to their mother.

"Staff, while coping, were struggling in packed [conditions]... we were asked to leave to make room for even more patients. While we were very reluctant to leave mam alone, we were given no choice," Ms O'Brien said.

"Over the next hour [my sister] Valerie tried to go back to mam's bedside but was repeatedly denied entry due to the overcrowding."

Family members remained in the waiting room at the hospital throughout the day, but they were not informed Ms Lyons had been moved to intensive care, nor were they told she was due to undergo a surgical procedure, Ms O'Brien said.

"At 5.55pm, Valerie again tried to get back in to see mam only to be advised she was still there and she was doing fine, but she had been moved to ICU at this stage," added Ms O'Brien.

She said the family felt "stonewalled" and "dismissed" by the HSE whenever they attempted to get information on their mother's treatment.

Ms O'Brien said they were invited to a meeting with hospital management in March 2017 and management "agreed this was unfortunate and should not have happened".

"In their own words, they said they 'failed' the family. Another comment was made that they would 'learn' from it, so no other family would suffer the same way."

Ms O'Brien said the family received its "first official information provided in correspondence" from management on July 30, 2018, 19 months after her mother's death, adding: "We feel this cold, clinical, cruel lack of engagement has left us feeling hurt and betrayed by the management of UL hospital."

Ms Lyons died during a "renal replacement therapy" procedure after her kidneys had failed. The inquest heard it was a routine procedure with a very low risk to the patient.

Dr Andras Mikor, a senior registrar at UHL at the time, carried out the procedure and said he called for assistance because he could not remove a surgical wire guide that had been inserted in Ms Lyons's neck to deliver fluids and medication.

Snagged

When the wire was eventually removed it was found to have "a kink" in it, which it was accepted had probably "snagged" on Ms Lyons's right internal jugular vein, causing it to tear.

Ms Lyons was pronounced dead a short while later, after attempts to drain fluids and perform CPR had failed.

Since the fatal incident, a new type of wire has been in use at UHL, the inquest heard.

A post-mortem examination concluded death was due to hypovolemic shock as a result of a torn vein.

Limerick Coroner John McNamara said a verdict of medical misadventure "does not carry any implications" for the clinicians involved in Ms Lyons's treatment, who said they had done their best to "fix her".

A solicitor for the HSE offered her "sincerest apologies and sincerest condolences" to the Lyons family.


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