Overview of the Inquest Verdict
In an inquest held in Dublin, a coroner concluded that the death of Marie O’Mahony, a 65-year-old woman from Rathfarnham, was due to medical misadventure. The finding does not attribute fault, but it acknowledges that an intended medical action led to an outcome that was not anticipated.
The Timeline of Events
Marie O’Mahony was admitted to St Vincent’s Hospital in the early hours of August 24, 2020, after coughing up blood, an alarming symptom that prompted urgent medical assessment. Although triage identified her as needing attention within two hours, her first examination occurred around 9am. A differential diagnosis raised the possibility of a pulmonary embolism, and she was treated with blood thinners while further tests were arranged.
During the evening, Marie underwent a computerised tomography (CAT) scan to evaluate her lungs. Tragically, she experienced a large bleeding event in the lungs followed by a heart attack. She never regained consciousness and died on August 27, 2020.
The Medical Assessment and Decisions
Dr Nichola Boyle from St Vincent’s Hospital outlined the initial assessment, noting that the patient’s history of sarcoidosis complicated the clinical picture. Sarcoidosis is an inflammatory condition that can affect the lungs and mimic or obscure other conditions. The medical team considered a pulmonary embolism as a potential complication and followed guidelines that recommend prompt treatment when such a diagnosis is suspected. This included the use of blood thinners and scheduling diagnostic imaging.
As part of the inquest, it was explained that a definitive diagnosis depended on imaging results. The CT scan, which could have clarified whether a clot was present, was being performed at the time Marie’s condition deteriorated, leading to a critical bleed and subsequent cardiac arrest.
Family Tributes and Personal Reflections
Marie O’Mahony’s husband, Michael O’Mahony, spoke at the inquest about the life they shared. He described his wife as a loving partner who brought joy to their family. He recalled meeting Marie at a Brendan Bowyer concert in 1982 and said she was a devoted wife, a caring mother to their children, and a loyal friend to many. In a poignant moment, he asked for the opportunity to speak about the woman he knew and cherished, even within the constraints of Covid-19 restrictions surrounding her funeral.
Mr O’Mahony’s testimony highlighted the personal impact of the tragedy, emphasizing the everyday kindnesses and the quiet strength of his wife. His reflections provided a human context to the clinical proceedings, illustrating how medical outcomes affect families beyond the hospital walls.
Coroner’s Findings and Next Steps
Coroner Dr Myra Cullinane delivered a verdict of medical misadventure. She stressed that this finding does not equate to a formal finding of fault by any individual clinician. Rather, it indicates that an intended action—treatment for a suspected embolism—was followed, but the resulting outcome was not what was anticipated. The distinction underscores the complexities of medical decision‑making in acute care settings where multiple factors can influence patient trajectories.
Context and Implications
Cases like this illuminate the challenges faced by hospitals in managing patients with complex histories, such as sarcoidosis, while ensuring timely interventions for potentially life‑threatening conditions. The inquest process aims to clarify what occurred and why, offering some closure to families while guiding future practice. The finding of medical misadventure may prompt ongoing review of protocols, particularly around triage timing, diagnostic pathways, and the balance between rapid treatment and thorough confirmation of a diagnosis.
About the Case
The incident took place at St Vincent’s Hospital in Dublin, with the proceedings reflecting both clinical realities and the emotional toll on Marie O’Mahony’s husband and family. The inquest confirmed the sequence of events from admission to the eventual outcome, emphasizing that the ultimate prognosis was not aligned with the intended therapeutic actions.
