Death of father ‘preventable’ and ‘avoidable’, inquest finds

A father of two young children who died at the Causeway Hospital in 2019 after being given an incorrect dose of antibiotics would still be alive if he had been “adequately treated”, a coroner has found.
Coroner Louisa Fee said the death of Christopher Trolan from Co Antrim occurred in circumstances which were “preventable and avoidable”.
She said a series of opportunities were missed to correct the erroneous prescription of antibiotics to Mr Trolan, who was 37 at the time and the father of sons aged two and 13 weeks.
The family of Mr Trolan have said they hope lessons can be learnt from his death.
Mr Trolan was admitted to the Causeway Hospital in Coleraine on November 5 2019 suffering from increased temperature and weight loss. He was diagnosed with endocarditis and died on November 26 after the infection spread.
Delivering her findings in the inquest at Laganside Courthouse, Ms Fee said that on November 8 he was prescribed benzylpenicillin intravenously.
However, she said he was incorrectly given the antibiotic five times a day, rather than six, resulting in him receiving a sub-therapeutic dose.
The coroner said there were a number of missed opportunities between November 8 and 22 to correct the error.
She said: “I find that the opportunity to identify the prescription error was missed at each ward round undertaken between these dates.
”The coroner told the court that Mr Trolan’s condition had begun to deteriorate on November 21. She said the prescription error was then identified the following day and corrected.
But she said there was a failure to document the mistake in the patient’s notes or records.
Ms Fee said: “I pause to note that it is somewhat striking that the notes do not detail such an integral feature of the deceased’s treatment and management, nor highlight the error which clearly occurred.”
She said there should have been an urgent discussion with Mr Trolan and his family to explain the error, but this did not happen.
The coroner told the court that as Mr Trolan’s condition continued to deteriorate, his sister raised concerns with medical staff on the ward, but there was “a failure to place appropriate emphasis on her concerns”.
She said a CT scan later revealed the existence of a large bleed on Mr Trolan’s brain.
The coroner found that the earlier failure to eradicate the infecting bacteria resulted in the continued release of bacterial toxins which caused him to have symptoms of sepsis.
She said: “I find that if the prescription error had been corrected at an earlier date, the intracranial bleed would still have been avoidable.”
Ms Fee continued: “I find on the balance of probabilities that the death of the deceased occurred in circumstances which were preventable and avoidable.
“I find that if the deceased had been adequately treated from 8th November 2019 he would have survived.”
She found that the death was due to an intracerebral haemorrhage while receiving treatment for mitral valve endocarditis complicated by disseminated intravascular coagulopathy.
A statement from the Trolan family, which was represented by O’Reilly Stewart solicitors, said the loss of Christopher was avoidable.
It added: “Christopher was 37-years-old when he died in Causeway Hospital and his loss has been devastating for his entire family, in particular his wife and two young sons who were aged just two years old and 13 weeks old at the time.
“Although today’s verdict brings closure on what has been a prolonged and extremely difficult five-year review of Christopher’s care, it confirms what we, his family, have always believed.
“That is, that Christopher’s death is highly likely to have been avoided had Causeway Hospital provided the appropriate treatment.
“The significant errors made by the hospital, and the fact that these went undetected for such a prolonged period of time, are evidence of substandard care and systemic failure.
“We can only hope that lessons are learned from Christopher’s death so that other families do not have to go through what we have done.”
A spokesperson for the Northern Trust “apologised unreservedly for the failings in care that have been highlighted”.
The spokesperson added: “We fully accept the coroner’s findings and will take time to reflect on the learning.
“The trust has already undertaken an investigation into Mr Trolan’s care and identified learning which has been shared with staff.
“This is a very tragic situation and we are deeply sorry for the family’s pain and loss.”
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