The family of a woman who died of a cardiac arrest due to blood clots in her lungs, just hours after she was discharged from University Hospital Limerick, has issued High Court proceedings against the Health Service Executive (HSE).
The proceedings, being brought by Eve Cleary’s parents and siblings, claims medical negligence and an alleged breach of duty of care to Ms Cleary.
The matter was filed prior to the holding of an inquest into Ms Cleary’s death held last week at Limerick Coroner’s Court.
The hearing heard that the 21-year old from Corbally, Limerick, died at University Hospital Limerick (UHL) in the early hours of July 21st, 2019, just four hours after she was discharged with a suspected soft tissue injury. She had a swelling in her leg and was in severe pain.
She had initially presented at the hospital on July 19th with a suspected fracture following a fall and was triaged to the Emergency Department (ED) as an urgent patient.
Ms Cleary spent 17 hours on a trolley in a cramped corridor of the overcrowded ED and near a foul smelling sink that had been used as a toilet by another patient, the inquest heard.
She presented at the hospital with a number of risk factors for blood clots, including that she was taking a prescribed contraceptive pill which specifically increased the risk of blood clots, was a smoker and was overweight, and had a family history of blood clots.
Ms Cleary was admitted as inpatient for a CT scan on her leg, but her ED medical files appeared to be missing, and nurses stationed on her ward were not fully aware of why she was there.
Staff at UHL told the inquest that screenings for blood clots were not routinely performed on patients presenting with acute trauma injuries.
Ms Cleary was not assessed for risk of blood clots and she was not seen by a consultant.
Her CT scan showed no abnormalities and she was discharged and told to rest her leg at home.
Four hours later Ms Cleary went into cardiac arrest and she was rushed back to UHL by ambulance. She was pronounced dead a short time later.
A postmortem found the cause of death was due to cardiac arrest due to extensive bilateral thrombo-embolisation, otherwise “clots”, in her lungs.
Coroner John McNamara returned a verdict of medical misadventure.
Mr McNamara said the case was one of “missed opportunities”. However, he stressed this was not to fault anyone involved in her care.