An inquest into the death of a 79 year old man heard of a systems failure of a cardiac team alarm system at South Tipperary General Hospital.
Coroner Paul Morris told the jury that the man, Mr. William Darcy, Deansgrove, Cashel, died of natural causes but that an inquest was held to investigate the circumstances of his death and to ally concerns the family may have. Mr Morris said that the man’s death had no relevance to the failure of the system.
The family were never informed by the hospital staff about the failure of the cardiac team alert system and were only told about it when the deceased’s widow Eileen noticed something in the medical notes and made enquiries some months later.
Mr. Darcy, described by consultant cardiologist and physician Niall Colwell as a very frail man who suffered from a multiplicity of health problems, died on the morning of January 6, 2010. He was discovered dead in his bed by nursing staff, when found he was cold, was not breathing and was unresponsive.
Nursing staff went to trigger a cardiac arrest team by pressing a button in the room that would alert the team. The system did not work and the nursing staff had to manually contact the switchboard to ask them to alert the cardiac arrest team.
The inquest was told that nursing staff activated the automated alarm system in the room the deceased man was in and in another room but it did not work.
The inquest was told that the failure was put right almost straight away.
Electrical consultant Darren Byrne said a switch in the reception area which had a note on it ‘never switch off’ was actually switched off which meant that the cardiac alarm system was not powered up. It would have run on batteries for about thirty minutes and an alarm should have gone off for that period to alert people that it was running on battery. He was called to the hospital that morning. He asked did anybody hear the alarm but nobody did. The system did not work because it was deprived of power. He replaced the unit with an unswitched unit so that it could not be switched off again. It cannot be turned off at that point again.
Doctor Niall Colwell told the inquest that Mr. Darcy suffered from a number of problems including diabetes, hypertension, chronic kidney disease and heart condition. He was admitted in January 2010 with a gastro intestinal bleed.
Asked by Cian O’Carroll, Solicitor, who represented the Darcy family, why he was not put on a cardiac monitor, Dr.Colwell explained that the ten cardiac monitors in the hospital would have been assigned to people who had heart attacks and they would gain precedence over somebody who was admitted with a gastro intestinal bleed.
Dr.Colwell said Mr.Darcy was found dead in bed by nursing staff and an attempt to trigger the automated system to summon the cardiac arrest team failed. The failure of the system had no effect on his death. The problem arose with a technical issue outside the remit of medical care. When Mr.Darcy was admitted his heart condition was not to the fore and he did not warrant acute cardiac monitoring.
Mr O’Carroll said there was an unwillingness on the part of the HSE to recognise that everything they do is not perfect. There was a time delay in the arrival of the cardiac arrest team, the system failed and a life could have been lost and the family hoped that lessons would be learned for the future. The family request for information was ignored on a number of occasions and it was only in January 2012 that they received the information they were looking for.
Mr, Walsh, representing the HSE management and clinicians, said nothing could be further from the case that the HSE was arrogant. The health services carried out its duties to the best of its abilities and the HSE does not have any policy of concealment.
Coroner Paul Morris said the fact that the cardiac alarm system did not work had no specific relevance to the man’s death other than it was an undesirable thing to happen in any hospital. The family were not informed about the systems failure and that caused unnecessary distress and anxiety to the family. That a candid explanation was not given early was likely to sow the seeds of doubt and probably suspicion in the minds of a family. It was regrettable that the family did not learn of this failure until some months later. If the explanation had been given early the family could have been reassured that the failure of the system would not have made any difference.
The Coroner said there were lessons to be learned as a result of what happened. He told the jury that the failure of the alarm system had no relevance to the cause of deathas the man was found dead ever before a button was pushed..T he way the family learned of the systems failure caused unnecessary distress and anxiety.
He recommended that the hospital should engage in more speedy and candid communication to the families in such situations and to the office of the coroner which should be informed of all the circumstances involved in such cases.
He recommended that there should be a risk review of the alarm system and that not only should the system itself be tested but that there should be a ‘dummy run’ in a malfunction situation as well as recommended by Mr. O’Carroll on behalf of the family. The review should also look at lengthening the length of the time the system can run on battery if it was forced to do so.