Pat Murphy (34) even had to get a taxi from his home to Cork University Hospital (CUH) because no ambulance was available, an inquest heard.
He only had a critical CT scan after he suffered a seizure, the inquest heard, as one of the CT scanners in CUH was broken.
His widow, Keerti, wept as she said she was “traumatised and scarred” by the thought that, in the hours before his death, her husband was not seen by a doctor despite being in such agony he had to lay on the floor rather than sit on an A&E department seat.
Today’s News in 90 seconds – 2nd October 2024
Dr John O’Mahony SC, for the Murphy family, said the man had suffered “an overwhelming delay – a huge delay where vital time was lost.”
The Murphy family also said they were further traumatised by the fact that sections of Dr Murphy’s observation care notes in CUH were missing from his file and could not be located.
Patrick ‘Pat’ Murphy died at CUH on September 3, 2021, two days after he was admitted.
It was confirmed the matter was referred to the National Incident Management Systems (NIMS).
Dr O’Mahony noted that the NIMS report, dated March 22 2023, found that the type of injury involved was “misdiagnosis – incorrect diagnosis.”
Mr Murphy, a chemical engineer, had complained of excruciating chest pains yet was initially assessed as having possible renal colic or a kidney stone.
His damaged artery was only diagnosed following an urgent CT scan after he had suffered a seizure.
CUH formally apologised to the family of Mr Murphy for failings in the care offered to him.
The Murphy family have been adamant that the delays were critical to the tragic outcome.
Mr Murphy, who held a PhD in chemical engineering and worked at Pfizer, went to CUH after complaining of severe chest pain on the evening of September 1, 2021.
The pain was severe and spread up his chest to his neck and around to his back.
He was assessed and ranked as a category-three patient. This meant he should have been seen within two hours.
Cork University Hospital
The hearing was told how he first became ill at 9pm on September 1 while watching the Ireland-Portugal soccer match on TV at home after the couple’s date night was postponed.
“I remember him getting animated in our sitting room…Cristiano Ronaldo was going to score a goal and Pat was telling him off,” Mrs Murphy said.
Suddenly, she said her husband was clutching his chest.
Mrs Murphy said her husband was in perfect health, ran road races and never complained about medical issues.
She said her husband immediately told her to ring SouthDoc, a GP service, which alarmed her as to the severity of his sudden condition.
“I clearly remember being frightened. Pat had had nothing like this before. Pat was in agony,” Mrs Murphy said.
After lengthy consultations on the telephone with a nurse and then a doctor, Mrs Murphy rang for an ambulance.
Her husband was in so much pain he could hardly talk.
Despite fears a cardiac incident was involved, it was so busy that night that no ambulance reached them within 45 minutes.
Eventually, it was decided that he would travel to CUH by taxi.
He arrived at 12.55am on September 2, was triaged, or assessed, four minutes later and should have seen a doctor within two hours.
However, the inquest was told he was not seen by a doctor until 9.30am.
At one point he warned: “I cannot stand the pain any more.”
An immediate CT scan was not conducted as one of the two CT scanners at CUH was broken and undergoing maintenance.
A CT scan was finally sought when he suffered a seizure – and it was immediately realised he had what is known as a dissecting aortic aneurysm, a condition where blood leaks into the lining of the artery.
The serious condition requires early diagnosis and urgent treatment.
A nurse slipped her hand in mine, suggesting I call a priest. The last ounce of my hope was destroyed
He underwent emergency surgery but died at 1.23pm on September 3.
Mrs Murphy said she had been clinging earlier to hope he would recover.
“He was hooked up to monitors, a tube through his mouth,” she said.
“His body seemed swollen and a foil blanket with layers of blankets barely kept him warm. I was taken away to speak to a surgeon who said he was ‘critical’. I knew the chances were slim, but I still held onto hope.
“When I walked back to his room, a nurse slipped her hand in mine, suggesting I call a priest. The last ounce of my hope was destroyed.
“The priest’s presence sank our hearts to the very bottom. I was directed by the priest to kiss Pat’s forehead and whisper that I love him and that [our son] Rohan loves him too.
“Then I heard the monitors flatline for the last time. I felt the pain and anguish ripping through my body. I could barely keep my footing. My home was where Pat and my boy were – and now our home will always feel incomplete.”
She said she cherished the last photograph she has of the young family in Cork city centre with little Rohan tightly holding on his father’s hand.
Mrs Murphy, a science graduate, said she and her husband’s family were later brought to two meetings at CUH in 2022 where the sequence of events was explained.
“What we heard though was far more haunting and scarring. We were told of nine hours waiting, not having timely access to functioning scans, that could have rerouted the misdiagnosis and missing pages of observation [notes],” she said.
“The hospital said they could not guarantee that the same thing would not happen again.”
Mrs Murphy said she and the Murphy family had since become involved with the Aortic Dissection Charitable Trust.
“With proper intervention and well-documented symptoms, many lives could be saved,” she said.
“No one should experience this traumatic course of events. My grief is still bitter, wondering how different things might have been with timely interventions?
“The only silver lining to all of this is, someday, Rohan might see it took a dozen people in the family to feel the strength of his Dada’s love, but it took one Dada to help save a dozen others, to never feel his loss.”
Mr Murphy’s sister, Yvonne, said the tragedy “shattered our hearts in ways we could never have imagined.”
“We hope that no other family will have to endure the pain we experienced,” she said.
The woman said they knew that “nobody personally went out to hurt Pat…it was just gaps in the system”.
Everyone was happy to wait for the CT scan, she said, “but that was not a good decision”.
A formal letter of apology was read out to Mrs Murphy and the Murphy family on behalf of CUH by Caoimhe Daly SC.
“We apologise unreservedly and sincerely for the failings in care during Patrick’s admission to CUH and for the failure to diagnose an aortic dissection,” the letter read.
“A review of Patrick’s care highlighted that a number of elements were not delivered as promptly as they should have been.
“We can assure you that lessons have been identified and shared across CUH to ensure that our clinical training processes are strengthened to avoid such a tragic outcome for others in future.”
Mr Murphy, of Coppervalley Heights, Glanmire, was originally from Donoughmore, Co Cork.
The inquest before Cork Coroner Philip Comyn is expected to conclude on Thursday.
