Rigor mortis had set in by the time staff found man dead on floor of overcrowded Limerick A&E, inquest hears

A man may have been lying dead for over an hour on the floor of University Hospital Limerick’s emergency department before he was discovered, and could not be ventilated by a doctor because rigor mortis had already set in.

The revelation came as the daughter of the late Martin Abbott (65) warned a Limerick Coroner’s Court inquest that she wants the circumstances of his death to serve as an urgent catalyst for change in Ireland’s healthcare system.

The death of Mr Abbott prompted a full systems analysis review at UHL.

Limerick Coroner’s Court recorded a verdict of death by medical misadventure as 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”.

“It all goes down to overcrowding,” he said as he stressed that the verdict was not a finding of fault or blame with hospital staff or any other body.

Mr Abbott’s daughter pleaded for change so no other Irish family suffers their needless loss.

“I just do not know how many more people have to die before the system changes,” Ann-Marie Abbott warned.

The coroner heard that conditions in UHL’s emergency department over December 16/17 2019 when Mr Abbot died were “very challenging”.

There were 141 patients in the emergency department on December 16/17, many acutely ill and on trolleys.

There were 54 patients in Zones B and C of the emergency department alone – with each nurse on duty being responsible for nine seriously ill patients.

Mr Abbott, who had a complex medical history, had his vital signs checked by nursing staff at 3am on December 17.

He had spent three days in UHL on a trolley waiting for a hospital bed.

The Shannon resident had been admitted to UHL on December 14 after complaining of pain, fever and diarrhoea.

Mr Abbott had received a kidney transplant several years before and, because of the steroids and anti-rejection medicines he was on, was considered immuno-suppressed and was placed in a cubicle in the emergency department on his own as he awaited a ward bed.

However, he was found lying face-down on the floor beside his trolley in a cubicle at 4.40am.

He was pronounced dead at 4.55am – with the inquest hearing that a ventilation or airway tube could not be inserted because the former taxi driver’s face and neck were rigid with rigor mortis.

Pathologist Dr Gabor Laskai said rigor mortis or postmortem rigidity usually sets in two hours after death.

However, that timeframe can be shortened due to factors such as fever, severe shock or sepsis.

The inquest heard it was possible that Mr Abbott may have been dead on the emergency department floor for over an hour before he was discovered by shocked nursing staff.

Ann-Marie Abbott – who described herself as “a Daddy’s girl” – said no one should endure what her family went through over the circumstances of her father’s death.

“In my experience, nobody should go into a hospital, to be diagnosed with a treatable condition and die in that hospital surrounded by nurses and doctors,” she said.

“I believe the improper monitoring of his symptoms, a failure to review him at timely intervals, the misrecording of vital data and the fact that he was left unattended for such a long period of time when he should have been out of the accident and emergency unit and in a suitable ward were all contributors to my father’s death.”

“I sincerely hope that through uncovering the truths revealed in this inquest, UL Hospital Group can glean valuable lessons to prevent further needless tragedies.

“Dad’s death should not be in vain but serve as a catalyst for meaningful change and improvements in healthcare practices and management to ensure the well being safety of all patients.”

Ann-Marie and her mother had spent hours with Martin in UHL over the three days – but she admitted she was “uneasy, concerned and worried” leaving him on December 16, afraid that he was not being looked after correctly.

She told the inquest her family had also endured being told her father had suffered a fracture to his C6 vertebrae.

It later transpired that his vertebrae had not been fractured but that the ligament surrounding it had been torn.

The young woman – who only celebrated her 30th birthday with her father a few weeks before his tragic death – works for the HSE.

“I am here today as a voice for my father – and I do not want to be vilified for doing so in my professional career,” she said.

Barrister Luán O’Braoináin SC, for UHL, acknowledged to the inquest that shortcomings had occurred in Mr Abbott’s care.

“We acknowledge deficits in the care we gave to Mr Abbott,” he said.

“I have been asked to repeat that acknowledgement and to apologise again to the family for these deficits.”

Maria Lane BL, for the Abbott family, instructed by Caitriona Carmody solicitor, said the family had waited over four years for a public acknowledgement and apology of the deficits in care provided for Mr Abbott.

UHL had apologised for its care failings following the November 2021 external report.

“His care was severely compromised. It was not escalated. There was a lack of attention to what medical doctors had diagnosed as the treatment he required,” Ms Lane said.

Ms Lane also queried the length of time Mr Abbott lay undiscovered on the floor of the emergency department.

She claimed there was “a complete breakdown” of communication between the nursing staff and the medical team in respect of his care.

An external report into the incident has made a total of 26 recommendations in respect of UHL – many of which identified overcrowding in the hospital as a serious issue.

Action has been taken on all bar two of the recommendations.

Dr Laskai said that Mr Abbott had died from acute cardiac failure against a background of pneumonia, severe arteriosclerosis and hypoxia.

The pathologist said that the ligament tear near the vertebrae most likely occurred when Mr Abbott fell from his trolley onto the floor.

However, he stressed that this was not a factor in his death.

Mr Abbott was on two different types of antibiotics after being diagnosed with a Legionella infection which had caused Legionella pneumonia.

However, the inquest also heard that a cardex – a special record of the medicines administered to a patient – had been lost and not found in respect of his treatment.

Dr Liam Casserly, a renal specialist who had treated Mr Abbot for many years but was not on duty on the night of December 17, said the loss of such items in a busy and overcrowded emergency department was not unusual.

“We see this regularly,” he warned.

“It is very difficult when the staffing levels are low and you have a high number of critically ill patients.”

Dr Casserly said the key issue with Mr Abbott was that there should have been an escalation of his treatment given his deteriorating condition.

Mr Abbott’s oxygen saturation levels had dropped from the high 90spc into the mid 80spc and Dr Casserly said that should have been “a red flag” that evening.

He had been assessed at a care level of six, which should have warranted hourly checks.

His vitals were checked at 3am but he was not checked again until he was discovered at 4.40am unresponsive on the floor of the emergency department by his trolley.

“He was monitored but he could have been monitored more regularly,” he said.

“Escalation is the decision that should have been taken. A re-evaluation was warranted at that point. What should have been done was that they [the medical team] should have been contacted for a re-evaluation and a number of investigations including a chest X-ray.”

Dr Casserly said issues like the misplaced cardex happen with overcrowded conditions.

“But these are the problems you have with an overcrowded accident and emergency department,” he said.

UHL nurse Ann-Marie Mahony said conditions in the emergency department that night were “challenging”.

She broke down when she described the scene as nurses discovered Mr Abbott and desperately tried to revive him.

Nurse manager Hazel Banks said staff were so upset that they had to have two special briefing sessions over the next day.

“Staff were very distressed,” she said.

Registrar Dr Ronan Callanan was immediately called to the scene in the emergency department at 4.40am in a bid to help resuscitate Mr Abbott.

“There was rigidity in the face and neck indicative of rigor mortis,” he explained.

That prevented a ventilator tube or airways tube being inserted.

Mr Abbott was pronounced dead at 4.55am.

Mr McNamara returned a verdict of death by medical misadventure and said he supported all 26 recommendations in the UHL review report.

“He [Mr Abbott] should have been seen more frequently – his case should have been escalated,” he said.

The Abbott family, speaking through their solicitor Caitriona Carmody after the verdict, said they welcomed the coroner’s ruling and his comments on UHL overcrowding.

Mary and Ann-Marie Abbott were too upset to personally comment.

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