Case Studies: Healthcare

Coroner Finds Death Preventable at Inquest

Patrick Mullarkey , O’Reilly Stewart Solicitors,  acted on behalf of the family of Mr Denis Doran at an Inquest which proceeded during the first week of April 2019 before Mr P McGurgan, the Coroner for Northern Ireland.

Mr Doran died on 19th November 2016.  At the time he was aged 57 years. Mr Doran attended the Accident & Emergency Department of Craigavon Area Hospital on 29th August 2016.  He complained of chest pains which had been present for some time.  The chest pains were brought on by exertion or by walking, and that they eased with rest.  There was a relevant family history of cardiac problems.  Mr Doran was noted to have an elevated cholesterol level.

Notwithstanding the suspicion on the part of the three Junior Doctors, who treated Mr Doran during the course of his admission, that he was suffering from angina, when seen by the Consultant, Dr Asaduzzaman, on the day after his admission, he was diagnosed as suffering from chest pain secondary to a hiatus hernia.  He was discharged from care.

His General Practitioners continued to maintain a suspicion in relation to the origin of his pain. He was referred on two occasions to the Rapid Access Chest Pain Clinic at Craigavon Area Hospital.  Despite guidelines which require that persons referred to the Rapid Access Chest Pain Clinic should be seen within a period of two weeks, Mr Doran’s appointment was not offered until 11 weeks after the date of referral.  Mr Doran died whilst on the waiting list.

In a wide ranging narrative given by the Coroner on 5th April 2019, the Court found that Mr Doran’s death was preventable. He stated that multiple opportunities were missed to take a different course, thereby avoiding the tragic outcome.  In finding that the death should have been avoided, the Court identified a series of systemic failings which contributed to the ultimate outcome. Identified deficiencies included delays in assessment at an outpatient clinic due to resource issues and perceived inadequacies in the recruitment and appointment of Locum Consultants.

The Coroner directed that the Southern Health and Social Care Trust now conducts an urgent review into the deaths of other patients on the same waiting list. The Trust must then report back to the Court  with the findings of that investigation.  The Court will also write to the Permanent Secretary of the Department of Health to bring to his attention the circumstances of the Inquest and ensure that other similar healthcare fatalities may be avoided in future.

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