New twist on "Ireland woman's death"; Honest engagement of the Indian nurse

Doctors at the hospital have admitted negligence in the death of Ireland County Mayo woman Elise Cronin, 49, at St Vincent's University Hospital on October 17, 2021. In accordance with the procedure, there was no response to the immediate intervention of the doctors on the blood test results. The Mayo woman died a few hours later at the hospital. 

A hearing at Dublin District Coroner's Court found the County Mayo mother-of-four, of Convent Hill Crescent, Ballina, died of hypovolemic shock due to intra-abdominal bleeding. Pathologist Susan Aherne, who performed the post-mortem on the deceased, estimated that around 1.5 litters of blood had been lost. Dr Aherne said the bleeding was linked to an infection following the patient's operation.

Mrs Cronin-Walsh underwent surgery nine days ago to remove a pancreatic tumour and her gallbladder and spleen. The inquest heard that shortly after noon on October 17, 2021, laboratory staff tried to call her hospital ward with the test results.

The critical finding of the test was first noticed at 7pm that evening by Priya Jacob, an Indian staff nurse, who immediately informed the doctors about the patient's critical condition. Doctors did not respond to emergency intervention. 

Coroner Aisling Gannon found Mrs Cronin-Walsh unresponsive shortly after suffering cardiac arrest, before she died at 9.19am. The laboratory manager told the inquest that the blood test results were available from 12.05pm that day. The laboratory manager said that the laboratory staff tried to phone the two extensions in the patient's ward but there was no answer. He admitted that procedures for escalating critical findings to on-call doctors, who did not return calls, were not followed.

The consultant said the hospital's laboratory staff did not take any follow-up after calls to the patient's wards about the blood test results went unanswered. Doctor Maguire argued that the protocol stipulated that laboratory staff should contact the on-call medical staff or the surgical consultant responsible for the patient if they failed to arrive on the ward. "They did not follow this protocol and did not bring this low haemoglobin to anyone's attention," he admitted.

Doctor Maguire said he expected the patient to develop a post-operative intra-abdominal infection but her recovery was progressing as expected. The surgeon said he expected the patient's haemoglobin to be tested on October 16, 2021, but it did not happen. At the same time, he claimed, none of the other medical tests that day indicated anything wrong with her vital signs. Doctor admitted that Cronin-Walsh may have suffered a massive internal bleed the night before she died.

James Walsh, the deceased's husband, also gave evidence that the day before his wife's death her stomach had swollen up like a balloon with too much bile. When he left the hospital, his wife informed him that her body was telling her, she was dying, but James Walsh, said to her, “Don't talk like that. You will be fine.” The husband informed that. He recalled that he could not contact the hospital ward at any time the following day until he was informed that evening of his wife's death. "Mr Walsh criticized the care given to his wife by SVUH in the week after the operation, including when it took an hour for someone to help her go to the toilet. It is unbelievable to leave someone after a major operation," Walsh said.

At the end of the inquest, SVUH's solicitor, Caoimhe Daly BL, made a sincere apology on behalf of the hospital for its failure to care for the deceased, which led to her untimely death. She said changes have been implemented to improve patient care and practice to prevent recurrence of the disease. The hospital says procedures have been reviewed and updated since Cronin's death and all staff have been retrained on the communication of critical results.