Patient found on UHL floor may have been dead for over an hour, inquest hears

IT'S THE “sort of thing you read about in wartime situations”, a Clare TD has said after an inquest heard that a man may have laid dead for over an hour on a hospital floor before he was discovered.

The deceased could not be ventilated by a doctor because rigor mortis had already set in, an inquest has heard.

The inquest into the death of Martin Abbott, aged 65, of Deilginis, Shannon and late of Assumption Park, Roscrea took place in Kilmallock Court on Monday.

Mr Abbott died in the Emergency Department (ED) of University Hospital Limerick (UHL) on Tuesday, December 17, 2019.

UL Hospitals Group have issued an apology after being contacted by Limerick Live this Thursday.

"UL Hospitals Group wishes to express its sincere sympathy with the family of Mr Abbott on their loss. We strive to uphold the highest standards of patient care and safety, and it’s clear in this case, these standards fell short of what was expected.

"We apologise for the deficiencies and shortcomings in Mr Abbott’s care and for the distress and trauma this has caused his family," reads the statement.

Ralph Riegel, of the Irish Independent, reports that Limerick Coroner's Court recorded a verdict of death by medical misadventure. Coroner John McNamara warned that while Limerick has a proud reputation on the hurling field, UHL "is in the news for all the wrong reasons (because of) overcrowding”. Mr McNamara said the verdict of death by medical misadventure was not to blame anybody as that was not the role of the coroner’s court.

There were 141 patients in the emergency department on December 16/17, 2019.

Mr Abbott’s daughter, Anne Marie, wants the circumstances of his death to serve as an urgent catalyst for change in Ireland's healthcare system.

"I just do not know how many more people have to die before the system changes," Ms Abbott warned.

Clare TD Michael McNamara, who read the coverage this Thursday morning, said his reaction is “one of shock and anger”.

“That somebody would be dead for that length of time in an emergency department for them not to be aware of it is profoundly shocking. It is the sort of thing you read about in wartime situations, not a 21st century healthcare setting. It is profoundly shocking. 

“That combined with the HIQA report that was released in June 2022 based on an unannounced visit in March 2022 and then the death of Aoife Johnston the following December. The circumstances seem alarmingly similar to the risks highlighted in the HIQA visit,” said Deputy McNamara.

Mr Abbott, the Irish Independent have reported, had spent three days in UHL on a trolley waiting for a hospital bed.

Mr Abbott, who had a complex medical history, had his vital signs checked by nursing staff at 3am on December 17. He was found lying face-down on the floor beside his trolley in a cubicle at 4.40am.

The Irish Independent reports that a ventilation or airway tube could not be inserted because the former taxi driver's face and neck were rigid with rigor mortis.

Deputy McNamara said he has raised repeatedly the “entirely inadequate state of UL Hospitals Group and in particular the ED department”. 

“There are many excellent healthcare professionals working in UHL in all departments, including the ED, but the ED is simply dysfunctional. My constituents are afraid to go there and I don't think people should be afraid to seek healthcare but that is where we are at. 

“I am not suggesting for a moment that every death in UHL is preventable but certainly Aoife Johnston’s looks like it possibly was and to be dead for possibly over an hour before you are seen is unimaginable. I accept there is a problem in our healthcare system everywhere in our country but they are of a very different magnitude in the Mid-West to other parts of the country. We are not second-class citizens,” said Deputy McNamara.

The Independent TD said either the resources are inadequate or the management team is “not up to job of utilising those resources and I am not in a position to judge which is the problem”. 

“One way or the other there is a huge problem with UHL and it can’t be allowed to continue. Enough is enough at some point,” said Deputy McNamara.