In a regrettable incident that took place at Cork University Hospital (CUH), Beata Kunicka, 33, unfortunately lost her life due to a medical oversight by the hospital. Upon her initial visit to the emergency room, the hospital staff failed to identify that Kunicka, originally from Kanturk, Co Cork, had ingested her denture. After this misjudgement, the patient was erroneously allowed to go home.
This critical incident led to an overhaul of policies in hospitals throughout the nation. In an unfortunate turn of events, Kunicka made a second hospital visit, 17 days post discharge from her initial visit. She was severely ill, experiencing symptoms like collapsing at home and haematemesis. Despite the removal of the misplaced denture from her oesophagus, she tragically lost her life more than 20 hours later on October 12th, 2021.
The High Court revealed on a Friday court hearing that the hospital had offered an apology to the deceased’s family for subpar care. Legal counsel for Kunicka’s family, Gabriel Gavigan, highlighted that the Health Service Executive never contested liability for the incident. Following mediation, Kamil Jarzembski, Kunicka’s partner who initiated the legal procedures, received a settlement of €450,000.
Previously, on her first visit to the emergency room on September 25th, 2021, Kunicka had reported experiencing chest pain. She raised concerns about possibly having swallowed her denture, which consisted of two front teeth, a supporting pallet, and wiring. The hospital performed a chest X-ray and also assessed her ability to swallow by providing a small test meal along with pain relievers for her chest discomfort. However, due to a lack of evidence of a foreign object in the X-ray readings and her persistent ability to consume food and beverages, Kunicka was discharged.
During the court hearing, it was revealed that in a letter addressed to Mr Jarzembski last year, the hospital’s CEO, David Donegan, acknowledged and expressed remorse for the failure to detect the ingested dental plate in Kunicka’s body and for the resulting erroneous discharge on her first visit.
The letter revealed that medical professionals were initially oblivious to the fact that some dental prosthetics are not visible through X-ray imaging. They erroneously concluded that the patient could be safely discharged since she could eat and drink. In response, CUH hospital has nationally raised awareness about these risks and adjusted their local clinical education. According to her lawyer, Ms Kunicka was admitted to CUH again past 1am on October 12th. She didn’t receive an assessment in the emergency department until 7 in the morning, all the while vomiting blood. The hospital ordered a blood transfusion and a CT scan for her. Unfortunately, she collapsed again and underwent surgery to have the denture removed. Severe blood loss required additional stabilisation.
It was alleged that further treatment was delayed due to differing medical opinions regarding her diagnosis. As a result, an extended discourse about her case ensued. Ms Kunicka became critically unstable, experiencing bleeding from her mouth, nose, and ear, with her condition continuing to decline until she went into shock. Despite efforts to resuscitate her, she succumbed to a cardiac arrest.
In a letter shared in court, the CEO of the hospital admitted that Ms Kunicka’s care upon her return was complex and challenging, but it is evident that the necessary care elements were delivered too late. Ongoing discussions about the cause of the bleeding and the optimal approach for treatment, coupled with the lack of immediate expertise, further delayed her necessary care.
Ms Justice Leonie Reynolds expressed sympathy to Mr. Jarzemnski and their young daughter, Julia, for the traumatic sequence of events. She offered the hope that the actions taken post-review would provide some comfort and help prevent such an incident from recurring in any Irish hospital.