The HSE has apologised to the family of a 67-year-old man for a “deviation in procedure” which triggered his death at Mayo University Hospital.
Dr. Simon Mills S.C., tendered a “sincere apology and condolences” to Geraldine Best, widow of Martin Best, and her family, at an inquest hearing in Swinford this morning.
Dr. Mills made the apology after the Coroner for Mayo, Pat O’Connor returned a verdict of misadventure at a hearing into the death of Martin Best, 3 Childers, Heights, Ballina, at MUH on January 12, 2019.
Mr. O’Connor was asked to conduct an inquest into the death by the Attorney General at the request of the Best family through their legal representative, Johann Verbruggen (Callan Tansey & Co).
Evidence was given at a previous hearing that policy procedures for the removal of central venous catheter (CVC) lines were not followed in Mr. Best’s case
Mr. Best was admitted to MUH on January 1, 2019. He was receiving treatment for advanced chronic obstructive airway disease (emphysema) and lower respiratory tract infection
After becoming unwell, two days later, he was moved to ICU. A day later he was transferred back to the medical ward and a plan was made to remove a central venous line.
Evidence was given at a previous inquest hearing that policy procedures for the removal of CVC lines were not followed.
The coroner was told Mr. Best was allowed sit up from the procedure sooner than recommended.
Also it is stipulated that CVC lines should be removed with two people present but IN Mr Best’s case there was only one.
In a statement read to a previous hearing, Dr. Muhammad Iqbal, Medical Registrar conceded that he “accepts with the benefit of hindsight that allowing Mr. Best to sit up (in a chair beside the bed) was a deviation from accepted protocol”.
The medical cause of Mr. Best’s death was outlined by a pathologist as “arrhythmia secondary to cardiomyopathy, pneumonia, chronic obstructive airway disease and ulcerative colitis”.
Coroner O’Connor said today that in his view the removal of the CVC line on January 8, 2019, was the trigger for the deterioration in Mr. Bests’s medical condition.
He then returned a verdict of misadventure.
Nine members of the Best family were in the public gallery for the hearing. Some broke down in tears on hearing the verdict.
Afterwards, Mr. Best’s widow, Geraldine, speaking on behalf of the family, said: “Martin was let down twice. He was put in danger’s way by being allowed to sit up so soon after having the central line taken out of his neck..
“Then, when recording his death, the hospital made no mention of this serious incident and Martin’s catastrophic injuries. The least he deserved, and he least every patient deserves is accurate recording how they died.
“How many more deaths have occurred in unnatural circumstance, which have not been properly recorded”.