“Preventable and Avoidable”.
Patrick Mullarkey of O’Reilly Stewart Solicitors, acted on behalf of the family of Christopher Trolan in this inquest which proceeded before Coroner Fee in Belfast from Monday 9th to Friday 13th September 2024.
The inquest considered the circumstances of a healthcare fatality where a young man, aged 37, died of an treatable illness (endocarditis) due to a dispensation error in the Causeway Hospital, Northern Trust.
Christopher was admitted to hospital on 5th November 2019 due to an infection which was causing endocarditis, an infection of the lining of the heart. He received a sub-therapeutic dose of antibiotics for a prolonged period of time which failed to eliminate the infection. Instead of receiving the medication six times per day, as had been prescribed, it was dispensed in error five times a day. The error in dosing persisted until 22nd November 2019. It precipitated disseminated intravascular coagulation and acute kidney injury, leading to death. He leaves behind a wife and two young children.
Today Coroner Fee made her findings as she delivered her verdict into Christopher’s death. Having considered all of the evidence over the course of the hearing and having been greatly assisted by the medical experts reporting to the Court, the coroner concluded that the death was “preventable and avoidable”. In so finding, the coroner identified multiple missed opportunities and failings which contributed to the tragic outcome in Christopher’s care. Failings included the initial failure to correctly record the prescription of the medication, the failure over each subsequent day to pick up the error on the Kardex, failure to devise an appropriate management plan when the error was identified or to respond adequately to Christopher’s deteriorating condition and failure to refer Christopher for urgent care. The coroner noted, with concern, that the error was never disclosed to the patient or his family, until after the death, and she could not be satisfied as to why he was not told.
The family, present in Court for the verdict, comment, “We would like to express our gratitude to the Coroner for undertaking a comprehensive inquest into Christopher’s death. Christopher was 37 years old when he died in Causeway Hospital and his loss has been devastating for his entire family, in particular his wife and two young sons who were aged just 2 years old and 13 weeks old at the time. Although today’s verdict brings closure on what has been a prolonged and extremely difficult five year review of Christopher’s care, it confirms what we, his family, have always believed. That is, that Christopher’s death is highly likely to have been avoided had Causeway Hospital provided the appropriate treatment. The significant errors made by the hospital, and the fact that these went undetected for such a prolonged period of time, are evidence of substandard care and systemic failure. We can only hope that lessons are learned from Christopher’s death so that other families do not have to go through what we have done.”
