An inquest was informed that an internal examination has been undertaken, and contrition was conveyed to the relatives of a 74-year-old woman, whose body was discharged from medical care before a requested postmortem by the coroner was conducted. The Dublin District Coroner’s Court was informed, in its Thursday session, about the sudden and unexpected demise of Olive Doyle on November 4th, 2023.
Ms. Doyle, a resident of Bray, Co Wicklow, was admitted to St Vincent’s University Hospital on October 13th due to malignant melanoma, coupled with conditions such as asthma and chronic obstructive pulmonary disease. During her stay, she developed more health issues due to the side effects of her immunotherapy treatment, that had serious toxic impacts that eventually led to her passing.
Ms Doyle had been hospitalised continuously until she died. Her cause of death was noted as infective COPD exacerbation and pneumonia, spurred by severe refractory immunotherapy toxicities. Aisling Gannon, the Coroner, acknowledged a ‘misunderstanding’ among the hospital staff, who had inaccurately believed that a postmortem was not necessary and had therefore handed over Ms Doyle’s body to her family.
Coroner Gannon clarified to the family that an investigation into the incident has been completed by St Vincent’s, asserting, “it has been highlighted that this mistake should not have occurred.”
A representative from St Vincent’s hospital, who had been interacted with the Coroner’s Court about this issue, couldn’t attend the inquest on Thursday. However, they reassured the coroner that such an error would not be repeated. The hospital extended an apology through the representative due to the communication errors leading to the release of Ms Doyle’s body without a postmortem.
The coroner admitted to the family that, regretfully, the situation remains that there is not enough information available, saying: “I’m aware of the lack of available information, and regrettably this situation is likely to persist.”
Ms Gannon expressed that although it was not typical to order and direct a postmortem without having accessibility, inquests frequently proceed without such requisites, especially when medical histories are attainable.
Advocating on behalf of the family of Ms. Doyle, Eavanna Fitzgerald, a barrister, noted that despite numerous queries remaining unresolved, they avoided any confrontational situations presently or in the future. She voiced that as a calm individual, Olive would not have sought out such circumstances. Ms. Fitzgerald conveyed the family’s anguish at the unexpected passing of Ms Doyle, labelled her as affectionate, highly upbeat, and deeply empathetic.
The inquest disclosed that Dr Yasar Ahmed, Ms Doyle’s consulting doctor at admission, was of the view that the potential benefits of immunotherapy outweighed the risks for Ms. Doyle, regardless of her existing medical conditions. However, he admitted being taken aback by the severity of the complications. Dr Ahmed highlighted that serious reactions like the one Ms Doyle experienced occur in 9 to 10 percent of patients and usually develop over weeks, not days. He recognises this reaction as ‘rare but acknowledged’, affecting approximately 1 percent of patients.
On behalf of Ms. Doyle’s family, Ms. Fitzgerald expressed a series of concerns, primarily the communication lapse during her stay as an inpatient. They had not been informed of Ms Doyle’s heart failure, which happened hours before her demise. Dr Ahmed, despite being on leave in the immediate days preceding her death, conveyed apologies on behalf of the clinicians available at the time for any failure in communication that might have braced the family for Ms Doyle’s passing.
The family also questioned the rationale behind the relocation of Ms Doyle seven times during her 23-day stay. Dr Ahmed acknowledged their exasperation, reasoning that health practitioners are not involved in patient relocation decisions.
Ms Fitzgerald revealed that the family was not wholly informed about the implications of bolstering Ms. Doyle’s decision to bypass intensive care unit admission following her decline in health.
In conclusion, Ms. Gannon indicated that a concise narrative judgment would be disclosed and subsequently communicated to the family at a later time.