Coroner in 'caffeine pills' case pledges hospital visit to check recommendations
A CORONER has described the care of a seriously ill patient left on a trolley for 45 minutes without being treated as "deeply unsatisfactory" and "not how the health service should operate in 2016 in this country."
Joe McCrisken was speaking as he delivered his findings at an inquest into the death of 23 year-old Edel Houston who died at Antrim Area Hospital after overdosing on dieting pills on June 2 last year.
The inquest was told that the 23 year-old Glengormley woman had 200 times the level of caffeine found in a normal cup of coffee in her body at the time of her death.
A Serious Adverse Incident report was produced by the Northern trust following her death and found that there had been failings in Miss Houston's care.
A series of recommendations made included introducing tighter regulations on hand-over procedures between ambulance and hospital staff, maintaining a heart monitor on patients at all times and ensuring that triage staff are aware that "their primary function is triage".
Mr McCrisken said: "Edel was left in a trolley for 45 minutes with no attention until she had a seizure.
"That is not how the health service should operate in 2016 in this country."
Dr Joe Lyness, assistant state pathologist, said that caffeine toxicity had been the "main factor" in the death, with aspiration pneumonia the "terminal event".
A keen swimmer, horse rider and member of the Girls Brigade, Miss Houston was registered blind and had difficulty walking.
Her father said she had developed mental health problems and anorexia after being bullied at school.
Mr McCrisken said: "The care of Edel Houston was deeply unsatisfactory. A Stage 1 call should and could have been made by the paramedic...the hospital should have been alerted to the condition of the patient."
"As I see it it was a very simple failing. The paramedic didn't see the seriousness of the situation and didn't communicate it to the triage nurse.
"The triage nurse didn't ask any questions of the paramedics and did not even bother to read the patient referral form. That failing is inexplicable."
However, a doctor and a consultant, who were both on duty, agreed it was "highly unlikely that earlier intervention would have changed the outcome".
The coroner, who said that "it is hard to know what quantity of tablets she took", told the court he intended to visit the hospital to see whether the recommendations arising from the death had been implemented.
Expressing his condolences to the family, Mr McCrisken said: "What we don't want is another family sitting here wishing that things had been done differently."