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Patient died in toilet as 'alarm wasn't heard'

HOSPITAL staff did not hear a critical heart monitor alarm which may have prevented the death of 47-year-old patient, an inquest heard.

Richard Cassidy, from Lissarda, Co Cork, was a patient in the cardiac ward at Cork University Hospital on February 25 this year when he was found dead at 11am in a toilet -- having suffered acute cardiac failure.

He had been admitted six days earlier after suffering a heart attack and underwent surgery where a stent was inserted in his coronary artery.

After being monitored in the Cardiac Care Unit (CCU), he was later moved to the step down unit next door.

Mr Cassidy's condition was being observed with a portable ECG heart monitor he was wearing. On the day he died, he was examined at 9.15am by nursing staff, who said he was, "feeling well, with no reports of chest pain".

The inquest heard that the monitor set off a warning alarm in the CCU at 9.32am. The alarm system triggered a red alert for 40 seconds.


According to biomedical engineer Bernard Murphy, the system was working properly and it could only be silenced manually. He told coroner Dr Myra Cullinane, "the red alarm is the system's highest priority -- it reflects a life threatening situation".

The inquest also heard that Mr Cassidy regularly went walking off the ward and had asked if he could be discharged that day. When staff realised he was no longer connected to the monitor, they paged the step down unit to reconnect him.

Staff Nurse Bernadette Flynn Kennedy said her pager went off at 10.05am and she went to check on Mr Cassidy, but was told by another patient that he "had gone off as usual".

Ann O'Dwyer, clinical nurse manager at the CCU, said she did not know who was at the station when the alarm went off. She also pointed out that the unit was full that day and a staff member had called in sick overnight. She said that staff tested the alarm afterwards and it could not be heard at the ends of the CCU.

The inquest was told new protocols had been introduced at the hospital. The jury returned a narrative verdict.