Man who died in hospital ‘would have been alive if he had received proper treatment’

A father of two young children who died after being given the wrong dose of antibiotics at Causeway Hospital in 2019 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 “preventable and avoidable” circumstances.

He said a number of opportunities were missed to correct the erroneous prescription of antibiotics for Mr Trolan, who was 37 at the time and had sons aged two and 13 weeks.

Mr Trolan’s family said they hoped lessons could be learned from his death.

Mr Trolan was admitted to Causeway Hospital in Coleraine on 5 November 2019 due to increasing fever and weight loss. He was diagnosed with endocarditis and died on November 26 after the infection spread.

Giving her findings at the inquest at Laganside Courthouse, Ms Fee said she was prescribed benzylpenicillin intravenously on 8 November.

However, he said he was incorrectly given the antibiotic five times a day instead of six, resulting in him receiving a less than therapeutic dose.

The coroner said there were numerous missed opportunities between November 8 and 22 to correct the error.

He said: “With every ward round carried out between these dates I find that the opportunity to detect the prescription error has been missed.”

The coroner told the court Mr Trolan’s condition began to deteriorate on November 21. He said that the prescription error was detected and corrected the next day.

But the error was not documented in the patient’s notes or records, he said.

Ms Fee said: “I paused to note that it was somewhat striking that the notes did not detail such an integral feature of the deceased’s treatment and management or highlight the error that had clearly occurred.”

He said an urgent meeting with Mr Trolan and his family was needed 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 voiced her concerns to medical staff on the ward but “due emphasis was not given to her concerns”.

He said a subsequent CT scan revealed the presence of a major haemorrhage in Mr Trolan’s brain.

The coroner found that the previous failure to destroy the bacteria causing the infection led to the continued release of bacterial toxins, causing him to have symptoms of sepsis.

He said: “I find that if the prescription error had been corrected at an earlier date, the intracranial haemorrhage would still have been preventable.”

Ms Fee continued: “On the balance of probabilities, I find that the deceased’s death occurred under avoidable and avoidable circumstances.

“I think the deceased would have survived if he had been adequately treated as of November 8, 2019.”

It found that death resulted from intracerebral hemorrhage while receiving treatment for mitral valve endocarditis complicated by disseminated intravascular coagulopathy.

In the statement made by the Trolan family, represented by O’Reilly Stewart lawyers, it was stated that Christopher’s loss was preventable.

He added: “Christopher was 37 when he died at Causeway Hospital and his loss was devastating for his entire family, especially his wife and two young sons, who were just two years old and 13 weeks old at the time.

“While today’s decision brings to an end a long and extremely challenging five-year review into Christopher’s care, it confirms what we, his family, have always believed.

“This means that Christopher’s death would most likely have been prevented if Causeway Hospital had provided appropriate treatment.

“The significant mistakes the hospital made and the fact that they went unnoticed for so long 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 did.”

A spokesman for Northern Trust “apologized unreservedly for the failures in care highlighted”.

The spokesman added: “We fully accept the coroner’s findings and will take time to reflect on what he has learned.

“The trust launched an investigation into Mr Trolan’s care and identified information shared with staff.

“This is a very tragic situation and we are deeply sorry for the family’s pain and loss.”