Mayo University Hospital

Medical misadventure ruling returned at inquest into young Mayo man's death

A verdict of medical misadventure was returned by a coroner today at an inquest into the death of a talented young Mayo student and footballer from an extremely rare and serious condition.

Adam Mulchrone, Sandyhill, Westport, died at Mayo University Hospital (MUH), Castlebar, on January 27, 2019, from multi-organ failure due to or as a result of meningococcal septicaemia.

The 21-year-old, a star player with Westport United F.C., was taken seriously ill while training with the club on the day before he died and was admitted to the emergency unit of MUH suffering from a headache, vomiting and a high temperature.

However, he was discharged from the hospital some hours later.

He died later in the hospital after being readmitted when his condition worsened.

Extensive evidence at the inquest into Mr. Mulchrone’s death was given during the course of a two-day hearing, conducted by the Coroner for Mayo, Pat O’Connor.

In his pathology report, Dr. Tamas Nemeth, who carried out a post mortem examination, said there was no evidence of meningitis or encephalitis.

He gave the cause of death as multi-organ failure due to (or as a consequence of) meningococcal septicaemia with neisseria meningitidis.

Dr. Nemeth said that in his 25 years as a pathologist – a period when he had carried out in the region of 4,000 autopsies – he had dealt with only two cases of meningococcal septicaemia.

At the outset of the hearing, Mr. Conor Halpin, senior counsel for MUH and hospital staff, said it was accepted that Adam’s vital signs should have been reassessed before he was discharged.

In a closing submission, Mr. Ciaran Tansey, solicitor, representing the Mulchrone family, asked for a verdict of misadventure stating there was more than sufficient evidence for doing so.

Mr. Halpin responded by saying he was not opposing a verdict of medical misadventure.

At the outset of the hearing, Mr. Halpin said it was accepted that Adam’s vital signs should have been reassessed before he was discharged.

After returning his verdict, Coroner O’Connor said he was heartened that the hospital had dealt with the matter in a fair, frank, open and accountable way.

He described the death as very harrowing especially for the parents and family

Mr. Halpin read a letter from Catherine Donoghue, General Manager of MUH, on behalf of the hospital and staff, to the Mulchrone family expressing condolences for their “immeasurable loss."

“We are truly sorry for the pain and distress caused you”, the letter read.

Mr. Halpin said the hospital gave an unreserved apology for what happened and promised that the ‘learnings’ from what happened will continue to be addressed in the emergency department.

Mr. Ciaran Tansey, solicitor (on behalf of the Mulchrone family) said Adam was in the prime of life and the loss for his family was a tragedy of enormous proportions.

Mr. Tansey said the family welcomed the hospital’s post facto recommendations and wanted to highlight to the public the symptoms of the disease – vomiting, headache and diarrohea – which took Adam’s life.

“Hopefully this will be the last case of meningococcal septicaemia which Dr. Nemath (pathologist) will have to deal with," Mr. Tansey concluded

During the hearing, Mary Mulchrone gave evidence in a witness statement that her son was discharged from hospital despite “the worst headache” he had in his life, was falling in and out of sleep and has red flares/patches on his chest.

Despite these symptoms, Mrs. Mulchrone indicated, her son was discharged from hospital but had to be readmitted later after his condition worsened.

Outlining the emotional impact of the tragic death on her and her family, Mrs. Mulchrone explained: “That day, January 27, 2019, our world changed forever.

“We lost her beautiful and kind son and brother, Adam. Our lives will never be the same again. Adam was a beautiful soul who was loved by many and was often described as ‘a true gentleman’.

“He was a fit and healthy 21-year-old man who was full of life and now he will never get to kick a football or laugh with his friends and family again”.