Mortuary staff unaware man had Hepatitis C virus

A man who died in UHG, seven days after collapsing in a friend’s garden last year, was found to have had a highly-infectious disease which had not been communicated to mortuary staff, an Inquest into his death heard.

Coroner for West Galway, Dr Ciaran MacLoughlin, said that while his main concern was for the people that his office employed, this was also a wider public health issue that needed to be further investigated.

“He had a contagious infectious condition, and because the people in the (mortuary) lab weren’t informed, the risk could have been passed on,” he said.

“People should be warned if someone has an infectious disease.”

He determined the cause of death, in accordance with the medical evidence, but deferred the case for another month to allow the consultant in charge at the time of his admission the opportunity to account for his or her actions.

Joseph McDonagh (65), of 68 Walter Macken Place, Mervue, died in UHG on August 1, 2017, having been admitted with a skull fracture a week earlier.

A family friend had told the inquest that he had called unexpectedly to her house in Bohermore on the evening of July 23 last. He was quite intoxicated on leaving, and had insisted on walking home. Early the next morning, however, a neighbour knocked at her door to say that a man was lying in her garden.

“She told me not to bother him, that he had been causing trouble,” the neighbour recalled in her deposition.

“I told her there was blood all over his head.”

He was taken to the emergency department of UHG, where his Glasgow Coma Scale, which records a patient’s level of consciousness, was 3/15. A CT brain scan revealed a severe head injury, and neurosurgeons in Beaumont Hospital deemed him unfit for transfer or for surgical intervention.

He was subsequently admitted to the Intensive Care Unit for one-to-one care.

Following hospital admission, Gardaí carried out door-to-door enquiries in the vicinity, but no neighbours recalled anything out of the normal.

“We did not establish any foul play in the head injuries sustained by Mr McDonagh,” Detective Garda Tom Doyle, told the inquiry.

Mr McDonagh’s condition did not improve, however, and he passed away on the morning of August 1 2017. Death was pronounced at 2.15am, and his remains were identified to Garda Damian Walsh by Mr McDonagh’s sister, Bridie Lawlor.

The death was reported to the Coroner, as are all unexpected deaths, and he directed consultant pathologist, Dr Margaret Sheehan, to carry out a post mortem examination.

While perusing past medical records, however, Dr Sheehan discovered that Mr McDonagh had the Hepatitis C Virus, an infectious disease affecting the liver that is spread by blood-to-blood contact.

She pointed out that neither she, nor the staff assisting her, had been warned of this.

She concluded that death was due to a massive traumatic injury to the brain, associated with a significant skull fracture. Pulmonary oedema and bronchopneumonia would have occurred after the injury, she added.

Dr MacLoughlin adjourned the inquiry for a month for the consultant on duty to make a statement, and to appear in person, to explain why a toxicology screening had not been performed on admission, including a blood/alcohol reading, and why mortuary staff had not been advised of the inherent danger posed by Mr McDonagh’s blood.

“This is a serious public health issue,” he said.

“Because I employ the consultant and mortuary technician, it is incumbent on me to ensure that the highest standards of health are afforded to all of these people.”

He advised the large McDonagh family, however, that despite this unresolved matter, a death certificate would be made available within a week.

He concluded that death was due to bronchial pneumonia and pulmonary oedema, as a result of a traumatic brain injury and a fractured skull, sustained in a fall.

“There is no evidence that he was the victim of an assault,” he added.

“A death certificate will be available, but we will call the consultant (on duty) to explain why the lab (mortuary) was not informed, and why an alcohol level was not taken on admission.”

The Coroner has also sought to find out if other hospital staff knew Mr McDonagh had this virus, and were barrier nursing care methods put in place as a result.