Pat Murphy (34) had to get a taxi from his home in Glanmire, Co Cork, to CUH because no ambulance was available, an inquest heard.
A CT scan was only performed after he suffered a seizure, as one of the scanners in the hospital was broken.
His widow, Keerti Murphy, 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 agony.
She said he was in such pain that he had to lie on the floor rather than sit on a seat in the emergency department.
Dr John O’Mahony SC, for the Murphy family, said the deceased had suffered “an overwhelming delay – a huge delay where vital time was lost”.
The Murphy family said they were further traumatised by the fact that sections of Mr Murphy’s observation care notes in CUH were missing from his file and could not be found.
He died at CUH on September 3, 2021, two days after he was admitted.
It was confirmed that the matter was referred to the National Incident Management System (NIMS).
Dr O’Mahony noted that the NIMS report, dated March 22 last year, found that the type of injury involved was “misdiagnosis – incorrect diagnosis”.
Ms Murphy said her husband was in perfect health, ran road races and never complained about medical issues
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 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 chest pain on the evening of September 1, 2021. The pain went 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.
The hearing was told he first became ill at 9pm on September 1 while watching a World Cup qualifier match between Ireland and Portugal on TV.
“I remember him getting animated in our sitting room. Cristiano Ronaldo was going to score a goal and Pat was telling him off,” his widow said.
Suddenly, she said, he was clutching his chest. Ms Murphy said her husband was in perfect health, ran road races and never complained about medical issues.
On clutching his chest, he told his wife to ring SouthDoc, a GP service.
“I clearly remember being frightened,” she said. “Pat had had nothing like this before. Pat was in agony.”
At one point, he said: ‘I cannot stand the pain any more’
After consultations on the phone with a nurse and then a doctor, Ms Murphy rang for an ambulance. Her husband was in so much pain he could hardly speak.
There was no sign of an ambulance after 45 minutes, so they travelled to CUH by taxi.
He arrived at 12.55am on September 2, was triaged 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 said: “I cannot stand the pain any more.”
It was found he had an aortic dissection aneurysm, a condition where blood leaks into the lining of the artery.
It requires early diagnosis and urgent treatment. Mr Murphy underwent emergency surgery, but died at 1.23pm on September 3.
Ms Murphy said she had been clinging to hope that 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.
A nurse slipped her hand in mine, suggesting I call a priest. The last ounce of my hope was destroyed
“I was taken away to speak to a surgeon who said he was critical. I knew the chances were slim, but I still held on to 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.”
Ms Murphy, a science graduate, said she and her husband’s family were later brought to two meetings at CUH in 2022, when the sequence of events was explained.
“What we heard was far more haunting and scarring,” she said. “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.”
Caoimhe Daly SC read out a formal letter of apology to the Murphy family on behalf of CUH.
“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,” it stated.
“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.”
The inquest before Cork coroner Philip Comyn is expected to conclude today.
