A Dublin woman developed a "unique" infection, the extent of which has never been seen before, after minor elective surgery at a private hospital, an inquest heard.
Susan McGee (52), from Skerries Road in Rush, Co Dublin died at Beaumont Hospital on July 24, 2013, eight days after being discharged from The Hermitage Medical Clinic following hernia surgery.
Dublin Coroner's Court heard the mother-of-two died from a rare Clostridium Difficile infection of her entire small bowel. Only 83 similar cases have ever been documented and consultant general surgeon Colm Power said he found none as extensive as hers.
Mrs McGee left The Hermitage on July 16 following recovery from her surgery but returned the following day. Her daughter Melissa Barry said she was "complaining of severe abdominal pain, vomiting and appeared distressed and uncomfortable". Her mother's condition worsened over the following days.
The family's legal team have raised concerns that she was not seen by any consultant over the weekend when her rapid deterioration started.
The consultant surgeon who carried out the original operation, Professor Arnold Hill, told the inquest he was on leave from Saturday, July 20 and handed over care to Mr Power. However, Mr Power said he did not know that a surgical registrar asked to attend to Mrs McGee would not be available on the Sunday and the first time he saw her was on Monday morning after she deteriorated.
Pathologist Dr Anne Marie O'Shea said Mrs McGee died from multi-organ failure having developed a severe C. Diff infection.
Risk factors included antibiotics, obesity and anti-acid reflux medication. Counsel for the family, Dr Simon Mills noted all three applied when Mrs McGee was readmitted to The Hermitage. She had been prescribed antibiotics following her operation.
When she returned to the clinic, a CT scan showed a small bowel obstruction.
On Friday, Mrs McGee passed a bowel movement and Prof Hill said he felt this indicated the issue was "resolving". When he passed her care on to Mr Power, he anticipated a "prompt" recovery, he said. He knew the surgical registrar would not be available to see her on Sunday. "I knew she was going to be seen on Saturday, I could not predict thereafter," he said.
Mr Power said it had been "agreed" the registrar would see her on Saturday and Sunday and contact him with any clinical concerns. He did not know the registrar was not available to see her on Sunday.
He saw her on Monday morning, 15 minutes after receiving a call that she had deteriorated significantly.
He performed a laparotomy that night fixing the obstruction. However, Mrs McGee continued to deteriorate and was transferred to intensive care at Beaumont where she subsequently died.
Mr Power said he executed her care to the "absolute best" of his ability, solving the bowel obstruction. "There was nothing I could do about C. Diff that affected 25 to 30 feet of her gastrointestinal tract," he said.