Coroner at inquest into death of man after surgery reiterates recommendations made in previous case
A coroner reissued recommendations made at a previous inquest that ‘mirrored’ the case of a man who died following surgery to remove a lump from his neck.
A verdict of medical misadventure was returned at the inquest of Brian Emmerson (71) from Greystones, Co Wicklow who died at St Vincent’s University Hospital in Dublin on May 6 2017.
Mr Emmerson suffered brain damage due to lack of oxygen caused by obstruction of his airway due to the formation of a hematoma in his neck two days after surgery.
Coroner Dr Myra Cullinane said she had issued recommendations following a similar inquest two years ago.
“I must refer to the fact I held an inquest in not dissimilar circumstances and I made a series of recommendations on that occasion and I find the steps taken in the aftermath of this tragic death mirror those made a significant period of time previously,” the coroner said.
Mr Emmerson underwent surgery on a 6.5cm lump on the left side of his neck as doctors wished to confirm whether it was malignant. The man had a number of background complications including heart disease, hypertension and type two diabetes. His warfarin medication was stopped to allow surgery to be performed and the anticoagulant medication clexane was to be reinstated post-surgery.
The surgery went well and a drain was in put in place at the site of the surgery. Consultant Tadgh O’Dwyer noted on the man’s chart that anticoagulant medication not be re-introduced until after the drain was removed.
However, clexane was reintroduced before the drain was removed due to communication issues at the hospital, an inquest heard. This was against hospital protocol, according to Mr O’Dwyer.
“He was still oozing a little from the wound edge. You would have thought it was reasonable not to give it (clexane). Protocol says you are not to restart the clexane until after risk has receded, which is after drain is removed,” he said.
Mr Emmerson’s condition deteriorated and he suffered cardio respiratory arrest shortly after midnight on May 6 2017. He was revived but suffered brain damage and died later that day.
The coroner reiterated recommendations previously issued in a similar case.
“Neck swelling post-surgery can lead to potentially life threatening complications and should prompt early review by a senior member of the Ear Nose and Throat team,” Dr Cullinane said.
“I had previously recommended that there be ongoing education in relation to these potentially life threatening complications.”
The hospital has implemented a number of training procedures in the wake of Mr Emmerson’s death, the court heard. The coroner endorsed these and said she would contact the HSE in relation to the formation of a designated app for communication between medical staff.
The coroner further recommended that the HSE review the provision of multi-site on call rotas and consider an on-site Ear Nose and Throat specialist at the hospital in the interest of patient safety.
