Died during gall stones procedure
Sligo Coroner Eamon McGowan recorded a narrative verdict into the death of 51-year-old Ita Reynolds who died from a heart attack during a routine procedure to remove gallstones at Sligo University Hospital in February 2013.
The catering assistant from Cornalagton, Leckaun, Co Leitrim, was undergoing an Endoscopic Retrograde Cholangio-Pancreatography (ERCP) to have her gallstones removed by Consultant Gastroenterologist Dr Kevin Walsh on Valentine's Day that year.
Dr Walsh testified at her inquest in Sligo Coroner's Court yesterday (Monday), that the procedure involved inserting a tube through the mouth, down the food pipe, through the stomach and the duodenum into the bile duct to remove the gallstones there.
Mrs Reynolds was not under General Anaesthetic but was given a combination of the sedative Mindazolam, painkiller Pethadine and Buscopan during the procedure.
The court heard she had been taking Temazepam sleeping tablets at night in hospital to help her sleep which, Dr Walsh said, "would also have raised her tolerance for the drug (Mindazolam)."
The court heard Mrs Reynolds received an initial dose of 6mgs of Mindazolam before the procedure which was topped up three more times to a total of 24mgs of the sedative.
Dr Walsh said the drug, which is regularly used for procedures such as endoscopies or ERCPs, was "short-acting and if a patient was overweight or younger "they might need more."
The court heard Mrs Reynolds had a body mass index of 31 which is termed clinically obese: "Ita Reynolds had a raised body mass index so she's going to need more sedation," he told the coroner.
Dr Walsh removed four gallstones. The patient's oxygen levels were constantly monitored and while they fell to 92% at one point, she had no breathing problems during the procedure according to Dr Walsh.
"If the patient's oxygen level was low that would be a sign of too much sedation but that never happened in this case," he said.
"We were on the last bit of the procedure when we noticed she was unresponsive," he told the court.
Antidotes to the drugs were given and CPR carried out but the woman was pronounced dead.
"We gave everything possible to see if we could revert it when the heart stopped," he said. "Unfortunately she had such a massive coronary she couldn't be resuscitated," he said.
He told the coroner he had carried out up to 27,000 such procedures over 17 years and had "never seen anyone get a heart attack during this procedure."
"Ita Reynolds was a smoker so her oxygen levels would be low anyway. We wouldn't stop a procedure if someone's (oxygen levels) were in the low 90's" he added.
Dr Walsh said Mrs Reynolds had an angiogram two years previously which was clear and she had no history of chest pain. He pointed out that she had also recently had two endoscopies with no problems.
"We had no idea she was harbouring such serious heart issues," he said.
Solicitor David O'Malley of Callen Tansey Solicitors, acting for Mrs Reynolds family, then argued that the type of heart attack she experienced had to have been triggered by an "external event", which he maintained, was not enough oxygen i.e. Hypoxia.
"She had severe coronary disease, you don't have to have an external factor. She had significant underlying coronary disease which she showed no evidence of," replied Dr Walsh.
"Have you ever given 24mgs to a patient?" asked Mr O'Malley. "We have. Her toxicology was low (0.1 ug/ml of Mindazolam). She wasn't behaving as someone knocked out," replied Dr Walsh, adding later that she wasn't given "an excessive dose."
Pathologist Dr Clive Kilgallen, who carried out the autopsy, told the court it was his opinion that death was due to "severe coronary disease" and that there was "no sign of respiratory depression as a cause of death."
In fact he concluded Mrs Reynold's heart attack could have started "well before the procedure without any warning signs, 2-4 hours before the procedure. There is no clinical evidence of hypoxia."
Dr Kilgallen said there was a fatty deposit blockage in her arteries which ruptured 2-4 hours before the procedure which blocked blood flow to her heart, causing the heart attack coincidentally during her gallstones procedure.
He also saw signs of previous "silent heart attacks what had gone unnoticed."
The Coroner Mr McGowan returned a narrative verdict after being "strongly swayed" by Dr Kilgallen's evidence.
He said Mrs Reynolds death was due to a blockage of blood to her heart precipitated between 2-4 hours prior to death while she was undergoing the ERCP procedure under sedation at Sligo Hospital while having underlying coronary artery disease. Sympathies were extended to the late Mrs Reynolds family in court.