The relatives of a 34-year-old loving father who tragically passed away after waiting for nine hours in a chair at Cork University Hospital (CUH) before a doctor attended to him, are urging that essential lessons be taken on board to avoid future tragedies. Pat Murphy, a chemical engineer from Cork, tragically lost his life to an aortic dissection on September 3rd, 2021, at CUH, after initially being incorrectly diagnosed with a potential kidney stone and renal colic.
On September 1st, 2021, Mr Murphy reported to the hospital late in the evening by taking a taxi after experiencing chest pain and a subsequent CT scan was scheduled. The arrival of Mr Murphy to the hospital was delayed due to a failed ambulance dispatch. As a triaged category 3 patient, the Lancaster University PHD holder should have been attended to by a medical professional within an hour of his arrival.
However, he was forced to wait for nine hours in the A&E department’s chair and his CT scan was delayed by 11 hours due to a malfunctioning CT scanner – one of two at the facility. The inquest unveiled that vital hours, which could have potentially saved Mr Murphy’s life, were lost as a result of the inappropriate diagnosis. Mr Murphy underwent emergency surgery but, unfortunately, efforts to salvage his life were unsuccessful.
A narrative verdict was delivered on his case on Thursday, determined by a seven-to-one majority vote. The inquest highlighted that Assistant State Pathologist Dr Margaret Bolster performed Mr Murphy’s autopsy, concluded that he expired from a dissected aortic aneurysm that resulted in the heart sac filling with blood. Dr Bolster further noted that Mr Murphy sustained severe brain damage due to lack of oxygen supply. The damage to the aorta was critically widespread. Dr. Bolster also warned that aortic dissection is a rare, potentially fatal condition that requires swift and accurate diagnosis and treatment.
“Aortic dissection is a critical condition with a mortality rate ascending 1 to 2 per cent every hour, necessitating rapid and accurate diagnosis and treatment,” relayed Dr Bolster. Extraordinarily, the occurrence of aortic dissection is uncommon in individuals below 40 years.
In the CUH emergency department, Dr Frank Leader, who’s in charge of education and training, was questioned regarding the nearly nine-hour time frame before Murphy was seen by a physician. The case was rated at category 3 and ideally, Murphy should have been attended to within an hour. Dr Leader highlighted the significant difficulty in adhering to the proposed time frame. Murphy’s case was thoroughly discussed in their monthly clinical risk conference, from which insights were drawn and shared across the department.
In the aftermath, CUH has enforced various improvements. This includes specific training for doctors about aortic dissection, recruitment of more experienced doctors, amplification of case discussions, enhancement of the email reference platform, and assignment of consultants to particular areas.
Heartfelt sympathy was expressed by the Coroner, Philip Comyn to the grieving family concerning their unexpected loss. He mentioned that the experience would lead to vital understandings. Murphy’s survivors include his wife Keerti Krishnan Murphy, their young child, his parents Willie and Noreen, as well as his siblings Sinead, Yvonne, Suzanne, and Tracy. Keerti and Yvonne Murphy indicated that imperative lessons must be acquired from this tragic incident in a bid to save lives.
The management of CUH has expressed regret to the Murphy family for their shortcomings in the way their loved one was cared for.