Overview of the case
A Dublin coroner has ruled that the death of Marie O’Mahony, a 65-year-old woman from Rathfarnham, was a medical misadventure. The finding was delivered after an inquest into her death following treatment at St Vincent’s University Hospital in August 2020. The coroner clarified that the verdict does not assign fault but acknowledges that an intended medical action led to an outcome that was not foreseen or desired.
The events leading to the tragedy
Ms. O’Mahony was admitted to St Vincent’s hospital around 4:00 a.m. on August 24, 2020, after coughing up a substantial amount of blood at home. Despite being identified in triage as someone who should be seen within two hours, she was not attended to until about 9:00 a.m. During the initial assessment, clinicians considered a pulmonary embolism as a possible diagnosis. In response to this differential, she was started on blood thinners, a standard treatment for suspected embolism, and a chest scan (CAT scan) was arranged for later that day.
Later that evening, while the scan was in progress, Ms. O’Mahony suffered a significant bleed in the lungs and subsequently experienced a heart attack. She never regained consciousness and remained unresponsive until she passed away on August 27, 2020.
The medical considerations and actions taken
During the inquest, Dr. Nichola Boyle of St Vincent’s Hospital outlined that Ms. O’Mahony had a history of sarcoidosis, a condition causing inflammatory changes in tissues, including the lungs, which can complicate clinical pictures. This history informed the initial risk assessment, with clinicians recognizing a possible pulmonary embolism and adhering to guidelines that advocate prompt therapeutic intervention, often including anticoagulation when embolism is suspected. The medical team nevertheless faced the challenge of distinguishing embolism from other potential issues linked to Ms. O’Mahony’s sarcoidosis and lung involvement.
As the case progressed, evidence showed that the crucial diagnostic scan could not reveal the underlying problem in time to avert the subsequent hemorrhage. Dr. Boyle indicated that the lung scan was performed at a point when the patient’s condition was already unstable, and the sequence of events culminated in a cardiac arrest. Counsel for the family asked when the doctors recognized that the initial diagnosis might be incorrect. The response in court was that the misdiagnosis was identified after the cardiac arrest occurred, a moment that shifted the focus of the case toward understanding the outcome rather than assigning blame on a single action.
The coroner’s verdict and its significance
Coroner Dr Myra Cullinane delivered a verdict of medical misadventure. In relation to this finding, she stressed that it does not involve a formal finding of fault. Instead, it acknowledges that an intended medical intervention occurred and that the consequences were not as intended. This distinction is important for understanding how such verdicts are used within the Irish medical system and for guiding future practice and patient safety improvements.
Following the verdict, Mr. Michael O’Mahony, the husband of Marie O’Mahony, spoke to the court with a touching recollection of their life together. He recounted meeting Marie at a Brendan Bowyer concert in 1982 and marrying four years later. He described her as a devoted wife, a caring mother to their sons David and Aidan, and a trusted friend to many. The couple had faced the trials of life together, and Mr. O’Mahony spoke of Marie’s kindness, generosity, and love of the small things that brought her happiness.
A personal tribute amid Covid restrictions
Mr. O’Mahony noted that Marie’s funeral took place under Covid-19 restrictions, a circumstance many families endured during the period. He asked for the opportunity to share memories of her life and express gratitude for the support of family and friends during and after her illness. He described Marie as someone who found joy in simple acts of care and who valued the presence of loved ones in her life.
Looking ahead
The inquest concluded with the understanding that medical misadventure findings serve to illuminate learning points for the healthcare system rather than to apportion blame. Hospitals and clinical teams continually refine protocols to reduce the risk of similar outcomes, especially for patients with complex medical histories such as sarcoidosis. The case underscores the delicate balance in emergency medicine between rapid assessment and careful consideration of confounding conditions that may mimic more common emergencies like pulmonary embolism.
