Hospital apologises after teenager dies from huge blood loss in routine surgery
A hospital has apologised to the family of a teenager who died after suffering massive blood loss following an injury to her aorta during routine surgery.
Jessica Sheedy (18), from Bruff, Co Limerick, died on May 11, 2018, three days after undergoing the operation to have a benign tumour removed from her abdomen.
An inquest into her death heard that, during the surgery, which was carried out at University Hospital Limerick, she suffered a “significant bleed” and lost seven litres of blood.
A post-mortem examination gave her cause of death as “multi-organ failure secondary to the removal of the tumour”.
Several theatre staff who were assisting Ms Sheedy’s surgeon, Mr Ashish Lal, told how, following the bleed, he refused to act on their repeated calls to seek assistance from vascular consultant surgeons.
Theatre nurse Catherine Browne said she “witnessed a huge gush of blood” “filling up” Ms Sheedy’s abdomen.
She claimed Mr Lal “refused” offers from her to get other surgeons to help him.
Theatre nurse Elaine Lyons said she also asked Mr Lal if he needed help, but “he said no”.
She said she telephoned on-call consultant vascular surgeon Eamon Kavanagh, and told him “we are in trouble in Theatre Six, Mr Lal is refusing help”.
“Mr Lal said he didn’t want any help,” she told the inquest before returning to her seat where she broke down in tears.
Dr Eoin Fahey, who also assisted Mr Lal, said there was “a sudden rush of arterial blood” during the operation, and Ms Sheedy’s blood pressure “dropped rapidly”.
Junior registrar Dr Helen Earley said she also asked Mr Lal “if he needed help, and he said no”.
She added that, if she had been performing the surgery, her “response would have been to call for help from another vascular surgeon, but I was just a junior trainee”.
Mr Kavanagh said “a major transfusion protocol was activated” which involved the team contacting the bloodbank for extra blood. This happened 20 minutes after the “significant bleed”.
About 40 minutes after the bleed, Mr Kavanagh arrived and repaired the aorta.
He said he was “very surprised” to get a call from Ms Lyons, as he “had no prior knowledge” of the surgery.
He agreed it was “usual” that he would have been consulted prior to similar surgeries, and that it would have been usual that vascular surgical support would be arranged to be on standby.
Before reading his deposition into evidence, Mr Lal offered his “deepest sympathy and condolences” to the Sheedy family.
“Not a day has gone by in the last 18 months that I haven’t thought about Jessica,” he said.
Mr Lal said he “could not see where the blood was coming from” and he had concentrated his efforts on removing the tumour, as he felt it was “obscuring” his view of the location of the bleed.
“I think, in hindsight, I would have had a second surgeon scrubbed in surgery,” Mr Lal said.
He also agreed that, in hindsight, he would have “immediately called in” help.
Noreen Spillane, acting chief executive of UL Hospitals Group, apologised “unreservedly for the sorrow and distress caused to Jessica’s family over her untimely death”.
Recording a verdict of medical misadventure, Coroner John McNamara said there had been “missed opportunities” in the teenager’s care.