Family disappointed inquest into father's death in CUH did not make more recommendations
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The family of a father-of-one who died in Cork University Hospital (CUH) after a broken CT scanner delayed his diagnosis say they are disappointed that more recommendations called for in his inquest were not adopted.
A broken CT scanner, early misdiagnosis and staff shortages all impacted the care of 34-year-old Dr Patrick Murphy before his death from aortic dissection on September 3, 2021. His wife, Keerti Murphy, and his family has called for learnings from his death — not just in Cork but nationally.
“Keerti and the Murphy family hope for lessons to be learned from Patrick’s death, particularly as they have received an apology from CUH for the failings in his care,” their barrister Doireann O’Mahony said.
“They believe that the recommendations they asked the jury to return had the potential to make real change. Nevertheless, they still hope that CUH will recognise this and engage with them to improve outcomes for others affected by aortic dissection.”
Dr Murphy, a chemical engineer and father of a 17-month-old son from Glanmire, Cork, suffered sudden and very severe chest pain while watching a soccer match on September 1, 2021. He was admitted to CUH after midnight on September 2, 2021.
He was initially misdiagnosed with renal colic — or kidney stones. A CT scan would have quickly ruled out this diagnosis but his CT scan was delayed because one of two CT scanners was broken.
His aortic dissection was only diagnosed more than 24 hours later after he suffered seizures and his blood pressure dropped dangerously low. He was rushed to emergency surgery and despite every effort by medics to save his life, he died hours later.
Through their legal team, Dr Murphy’s family had called for three recommendations.
The first was an audit of radiology equipment in CUH. Although CUH had replaced the two CT scanners in use at the time of Dr Murphy's death and added a third with a fourth on the way, Dr Gerald Wyse of CUH had said in evidence that they could use additional resources and personnel.
Bespoke guidelines on aortic dissection in the hospital were also called for as the guidelines in place "were not enough to save Pat," Ms O'Mahony said.
Thirdly, they called for lessons in the hospital from Mr Murphy's death in how to respond to aortic dissection, potentially with simulations for staff, lectures and training.
A narrative verdict was delivered by the jury of five women and three men at Cork Coroner’s Court following two days of evidence. They recommended that CUH move to an electronic record system “as a matter of urgency.”
Roger Murray, SC, head of medical negligence with Callan Tansey solicitors, said that aortic dissection is rare but the incidence could be as high as six in 100,000 people.
“That means that in a county the size of Cork, you could expect to see 36 cases a year. So it's very important that there are learnings from this. And that's the one point of solace that the family will take.”
Mr Murray acknowledged that the hospital had “learned lessons” from what happened to Dr Murphy. “They now have a policy in relation to disseminating information in relation to the tragic outcome here,” he said.
The “harrowing, difficult evidence” heard at the inquest will hopefully raise awareness about aortic dissection, Mr Murray said. And the one recommendation the jury made was a very important one, he said.
Some of Dr Murphy’s medical records were not available to the inquest and an electronic system would allow better management of files.
Mr Murray said: “We know records existed. We know that Patrick arrived in A&E soon after midnight on the 2nd [September 2021]. But no readings for his blood pressure or his vitals were available until he seized and collapsed at midnight between the 2nd and the 3rd.
“The clinician [in the inquest] said it was unacceptable that these vital readings weren't available and the hope is that through electronic records, records that are vital in relation to blood pressure and the recording of a patient's condition, won't be unavailable to an inquiry like this in the future.”