The HSE has apologised to the family of an elderly man who died with choking complications after it took a hospital a week to act on an X-ray that showed he had swallowed his own dentures.
The apology for the diagnosis delay, and for other failings in the care afforded to Daniel O’Leary, 91, originally of Knockbrack, Banteer, Co Cork, was issued on behalf of the HSE and University Hospital Limerick (UHL) and read out in the High Court in Cork on Wednesday, where Ms Justice Carmel Stewart approved an award of €55,000 to Mr O’Leary’s family.
The High Court was told Mr O’Leary was a resident of Kanturk Community Hospital, when at about 11.25am on July 26, 2022, he started coughing while sitting in his chair, and complained of something being stuck in his throat.
A bottom denture of two teeth was missing, he was in discomfort and was holding his hands to his throat.
Staff reacted quickly and he was rushed by ambulance to UHL, where doctors were told he had possibly ingested or inhaled a denture.
He was examined in the emergency department (ED), and X-rays of his neck, chest, and abdomen, showed no evidence of a foreign body, and he was admitted.
He was assessed in the ED again the next day, and nothing was found to suggest his upper airway was obstructed.
A doctor diagnosed respiratory sepsis, due to community-acquired pneumonia, on a background of likely aspiration, due to impaired swallow, and he was treated with intravenous fluids and antibiotics, and oxygen therapy.
Mr O’Leary was assessed again on Friday, July 29, and seemed to be improving. He remained in hospital over the bank holiday weekend.
A consultant physician and geriatrician took over his care on Tuesday, August 2, however, Ms Justice Stewart was told the chest x-ray taken the previous Tuesday was only reported on Saturday, July 30, and it showed “multiple linear densities in the upper neck, likely reflecting a foreign body”.
The court heard there was no evidence this report had been seen by, acknowledged or acted on by any medical personnel until the consultant physician and geriatrician came on duty on August 2.
A CT scan requested that day, and carried out on August 3, did not detect any foreign body in Mr O’Leary’s neck or thorax, but during a suctioning procedure later that day, nurses identified dentures in the lowest part of his throat.
They were removed by the ENT team the next day — nine days after Mr O’Leary was brought to hospital.
His condition deteriorated, and a decision was made to treat him palliatively, and he was transferred back to Kanturk Community Hospital, where he died peacefully on August 12.
The court was told while Mr O’Leary had severe underlying natural disease, an inquest had returned a verdict of medical misadventure due to delay in diagnosis.
The coroner recommended a review of the hospital’s reporting mechanism of significant and serious findings on investigations, and recommended a new system to allow these results be notified to and acknowledged by a senior doctor as soon as possible.
The court was told the coroner’s report from October 2023 said: “There appears to be currently a method of alerting staff by email but there is no evidence that this was effective in this case.”
The O’Learys’ barrister, Eamon Shanahan, instructed by solicitor Deirdre Kennedy of David J O’Meara and Son solicitors, of Mallow, read the apology in court.
It said: The hospital has learnt from the incident and has implemented the recommendation identified by the coroner at the inquest. We wish to apologise for the failings in the care provided and for the distress and upset that this has caused.”
Approving the damages, Ms Justice Stewart offered her condolences to Mr O’Leary’s family, including his children John, Margaret, Donal and Deirdre, his eight grandchildren, and two great grand children.
“Your father had a long and fruitful life,” she told his children.
“There is never a good time to lose a loved one, or to endure the trauma he endured. It doesn’t bear thinking about. Hopefully, you can put this behind you and reflect on the good times.”
The family paid tribute afterwards to the staff of Kanturk Community Hospital for the care they afforded to their father in his final years.