A coroner has returned a verdict of medical misadventure following the death of a 53-year-old man at St Vincent's University Hospital in October 2022.
The inquest heard that the man attended the emergency department with breathing difficulties and chest pain. A treatment plan that included anticoagulation therapy was set out in his notes at 4:45pm, but the prescription was delayed and the medication was never given. A CT scan that evening confirmed clots in both lungs. He became unresponsive before 11pm and died after midnight despite resuscitation attempts.
The coroner found that the delay in prescribing and the failure to administer the prescribed medication was at the heart of the case. The recommendations included improved staff education and clearer communication protocols for life-threatening conditions.
Read the full report at The Irish Times.