Cork University Hospital should “urgently” move to an electronic record system, an inquest into the death of a father-of-one who died after his ruptured artery was misdiagnosed, has recommended.
A broken CT scanner, early misdiagnosis, and staff shortages all impacted the care of Dr Patrick Murphy, 34, from Glanmire, Cork, before his death on September 3, 2021.
A chemical engineer with a PhD, the father of a 17-month-old son suffered sudden and very severe chest pain while watching an Ireland v Portugal soccer match on September 1, 2021.
He was admitted to Cork University Hospital after midnight on September 2, 2021.
A scan would later reveal that he had suffered an aortic dissection, a potentially deadly condition in which a tear occurs in the inner layer of the body’s main artery, the aorta.
With efficient diagnosis and treatment, people with this condition can survive.
But Mr Murphy’s diagnosis was not made until some 24 hours after he presented to Cork University Hospital, when he had a CT scan, an inquest into his death at Cork Coroner’s Court heard.
An initial consultation with a doctor produced a diagnosis of renal colic or kidney stones and this misdiagnosis was not picked up until his condition had deteriorated dangerously.
“Everyone was singing off the same hymn sheet but unfortunately it was the wrong hymn sheet,” Doireann O’Mahony, BL, barrister for the family said.
Pathologist Dr Margot Bolster said that Dr Murphy had died due to dissection of the aorta.
He also suffered severe brain damage caused by low blood pressure which prevented adequate oxygen reaching his brain.
Aortic dissection is “extremely rare” in those aged under 40, she said.
Dr Bolster said that she sees approximately 10 aortic dissections in Cork and Kerry per year but these are mostly in older age groups.
Prompt and proper diagnosis is vital to a patient’s chance of survival, she said.
Dr Murphy and his wife, Keerti Murphy, who met while they were studying science in Lancaster University, had been due to go on their first date since having their first baby, on the night he suddenly fell ill.
Dr Murphy was admitted to CUH A&E at 00.59 on September 2, 2021. Despite being in acute pain and having to lie on the floor in the ED to try to get relief, he was not seen until sometime after 8am the following morning.
He was initially misdiagnosed with renal colic or kidney stones and “every step taken and not taken was the result of that misdiagnosis,” Ms O’Mahony said.
Although he was referred for a scan, which would have ruled this diagnosis out, at 2.30pm that day, that was delayed because one of two CT scanners was broken at the time.
Dr Frank Leader, consultant in emergency medicine at CUH, gave evidence at Cork Coroner’s Court today.
Although Dr Leader, as a consultant on call, never reviewed Dr Murphy that night, he reviewed all available clinical notes and presented his findings to court.
Ms O’Mahony pointed to gaps in note-taking during Dr Murphy’s care, with no time given for when Dr Murphy was first seen by a doctor and paltry detail on the level of pain he was in, despite it being “probably the worst pain of his life”, she said.
Although Dr Murphy was initially triaged as a Category 3 patient, an urgent but non-life-threatening classification, meaning that he should have been seen ideally within one hour, he was not seen for at least eight hours.
But shortly after midnight on September 3, 2021, Dr Murphy suffered severe onset chest pain then seizures and was transferred to the resuscitation bay.
An urgent CT scan at 1.16am showed the dissection of his aorta.
He was transferred to emergency surgery. Despite multiple surgeries and every effort to save his life, he was pronounced dead at 1.23pm that day, September 3, 2021.
Dr Leader agreed with Coroner Philip Comyn that having electronic records in CUH would help with record management, as the times of consultations would automatically be recorded on patient notes.
Aortic dissection in those aged under 35 is “extremely rare”, he said.
Symptoms of aortic dissection could look like a range of alternative pathologies, including heart attack, a lung clot, or kidney or bladder stones, he said.
Due to resource constraints, it is “very difficult” to always ensure that patients are seen within the timeframe recommended at triage.
Category 1 patients — those deemed most urgent, with a threat to life, are seen most urgently. Category 2 patients, the next-most acute emergency category, are seen as close to the recommended 10-minute timeframe as possible.
Category 3 patients — the category Dr Murphy was deemed to be in — will often have to wait beyond the recommended one hour, he said.
The waits are due to demand on the system and a lack of trainees and consultants, which is a problem facing hospitals internationally, not just in Ireland, Dr Leader said.
The A&E in CUH is now the busiest in the country, Dr Leader said, seeing up to 300 patients a day and some 90,000 patients a year.
Since Dr Murphy’s death, changes have been made in CUH, Dr Leader said.
There is now more awareness on how “this devastating condition” of aortic dissection can be missed and misdiagnosed.
CUH has also a major increase in staffing, including at least a doubling of consultant working hours per week and a doubling in junior staff hours, since Dr Murphy’s death, he said.
Four additional advanced nurse practitioners have also been hired.
Ms O’Mahony said that it was “very important” for Dr Murphy’s family that their tragedy is a real catalyst for change, not just in CUH but nationally.
“They believe it is in your gift to shape safer futures for those with aortic dissection,” she said.
Dr John O’Mahony, Senior Counsel for the family, had called for a verdict of medical misadventure.
However, a narrative verdict was delivered by the jury of five women and three men after deliberating for more than one hour at Cork Coroner’s Court.
They recommended that CUH move to electronic record system “as a matter of urgency.”
But the legal team for the family had called for three other recommendations. The first was an audit of CT scanners in CUH. Although CUH had replaced the two CT scanners in use at the time of Dr Murphy’s death and added a third with a fourth on the way, Dr Gerald Wyse of CUH had said in evidence that they could use additional resources and personnel.
Bespoke guidelines on aortic dissection in the hospital were also called for as the guidelines in place “were not enough to save Pat”, Ms O’Mahony said.
Thirdly, they called for learnings in the hospital from Mr Murphy’s death in how to respond to this medical emergency or aortic dissection, potentially with simulations for staff, lectures, and training.
Coroner Philip Comyn extended his sympathy to the family and said it was “all the more tragic” because things could have worked out differently.
Dr O’Mahony said that this day would stay with the Murphy family forever.
“Nothing could be harder than losing a bright, shining star in his mid-30s,” he said.
Ms O’Mahony said that it is now “absolutely vital” for the Murphy family to get information out to both the public and to emergency department rooms about this condition so that symptoms can be recognised and CT scans can be ordered quickly for diagnosis.
