The Health Service Executive (HSE) has offered its "sincerest apologies" to the family of a woman who died after her jugular vein was torn during a routine surgical procedure two years ago.
Teresa Lyons's daughter Geraldine O'Brien told her inquest on Tuesday that, on the day her mother died, her family were forced to leave her alone in a "hugely overcrowded" emergency department at University Hospital Limerick.
The family were told by staff to leave seriously-ill Teresa (76) alone in the department as there was only room for patients, Ms O'Brien said.
A verdict of medical misadventure was retuned at the inquest held at Limerick Coroners Court.
Teresa Lyons, of Granville Park, Limerick, who had a history of diabetes, presented at the hospital on December 29th, 2016 vomiting and suffering with diarrhea.
She died eight hours later during a routine surgical procedure after her condition worsened, her inquest heard.
"We were very reluctant to leave"
Reading from the family's victim impact statement, Ms O'Brien said she and her siblings feel "guilty" because they never got a chance to say goodbye to their mother.
"Staff, while coping, were struggling in packed (conditions)... we were asked to leave to make room for even more patients. While we were very reluctant to leave mam alone, we were given no choice," Ms O'Brien said.
"Over the next hour (my sister) Valerie tried to go back to mam's bedside but was repeatedly denied entry due to the overcrowding."
Family members remained in the waiting room at the hospital throughout the day, however they were not informed Ms Lyons had been moved out of the emegency department to Intensive Care, nor were they told she was due to undergo a surgery procedure or any risks associated with it, Ms O'Brien said.
"At 5.55pm, Valerie again tried to get back in to see mam only to be advised she was still there and she was doing fine, but she had been moved to ICU at this stage," added Ms O'Brien.
She said the family felt "stonewalled" and "dismissed" by the HSE whenever they attempted to get information relating to their mother's medical treatment.
Ms O'Brien said they were invited to a meeting with hospital management in March 2017 and management "agreed this was unfortunate and should not have happened".
"In their own words, they said they 'failed' the family. Another comment was made that they would 'learn' from it, so no other family would suffer the same way."
Ms O'Brien said the family received its "first official information provided in correspondence" from management on July 30th, 2018 - 19 months after her mother's death.
"We feel this cold, clinical, cruel lack of engagement has left us feeling hurt and betrayed by the management of UL hospital."
Ms Lyons died during a "renal replacement therapy" procedure after her kidneys had failed.
The inquest heard it was a routine procedure with a very low risk to the patient.
Dr Andras Mikor, a senior registrar at UHL at the time, who carried out the procedure said he called for assistance because he could not remove a surgical wire guide that had been inserted in Ms Lyons's neck to deliver fluids and medication.
When the wire was eventually removed it was found to have "a kink" in it, which it was accepted had probably "snagged" on Ms Lyons's right internal jugular vein causing it to tear the vein.
Ms Lyons was pronounced dead a short while later, after attempts by medical staff to drain fluids and perform CPR had failed.
Since the fatal incident a new type of wire has been in use at UHL, the inquest heard.
Medical file upset
Having obtained their mother's full medical files under Freedom of Information legislation, Ms Lyon's family were caused further upset by odd language used on a computerised hospital form relating to their mother's death which recorded that "surgery was performed on the wrong body part".
Senior UHL clinician, Dr Catherine Motherway, who was brought in to assist in Ms Lyons's surgery said the procedure was carried out properly.
This internal hospital administration system was no longer being used, the inquest heard.
A post mortem concluded death was due to hypovolemic shock as a result of a tear to the right internal jugular vein.
"That was where the damage was done", stated Limerick Coroner John McNamara.
He said a verdict of medical misadventure "does not carry any implications" for the clinicians involved in Ms Lyons's treatment who told the inquest they had their best to "fix her".
A solicitor for the HSE offered her "sincerest apologies and sincerest condolences" to the Lyons family.
Speaking afterwards, Ms Lyons's daughter Valerie Stewart said: "I'm just delighted its over and done with. We've been through two years of absolute mental torture.
"My mother was taken away and we were left with (no answers)... the treatment we got from management is absolutely disgraceful," she said.
"But they have apologised and they have said they have now changed the policies and they have changed the wire that mam died from," she said breaking down.
Reporting by David Raleigh