Coroner recommends hospital carry out review of 'on call' arrangements after young woman's death

by Seán McCárthaigh

A verdict of medical misadventure has been recorded at an inquest into the death of a young Longford woman who experienced “a catalogue of failures” while being treated at the Midland Regional Hospital in Mullingar two and a half years ago.

Bryonny Sainsbury (25), a salon owner from Briskil, Newtownforbes, Co Longford, who suffered a serious brain injury after being struck by her horse, died in Beaumont Hospital in Dublin on August 31, 2021.

Ms Sainsbury sustained her injuries while holding her horse as a vet tried to put a tube into the animal’s mouth at a riding stables in Keenagh, Co Longford on August 26, 2021.

She was initially brought to hospital in Mullingar and was only transferred to Beaumont three days later after a serious deterioration in her condition.

Following two days of evidence from over a dozen witnesses at an inquest at Dublin District Coroner’s Court, coroner Cróna Gallagher returned a verdict of medical misadventure.

Counsel for Ms Sainsbury’s family, Esther Earley BL, told the hearing that the combination of failures and shortcomings in the care of the patient during her stay in Mullingar had led to a death which was “treatable and salvageable.”

“Had she been treated appropriately in Mullingar, she would not have died,” said Ms Earley.

The barrister claimed the evidence had demonstrated that staff in Mullingar had failed to keep experts they consulted in Beaumont apprised of changes in the patient’s condition which she said had begun early on August 27, 2021 when Ms Sainsbury was vomiting and complaining of the pain in her head.

She said they had also failed to inform staff in Beaumont of the results of various scans on the patient.

Ms Earley acknowledged that there was a dispute between the two hospitals over advice that had allegedly been given for regular checks to be carried out on Ms Sainsbury which would have highlighted her falling sodium levels.

The barrister said there was also confusion between consultants in Mullingar over who was responsible for the care of the patient at a time when it was obvious that her condition was deteriorating.

She noted that one witness – a consultant neurosurgeon at Beaumont, Donncha O’Brien – had given evidence that his medical team were powerless to act to treat Ms Sainsbury due to lack of communication by staff at Mullingar and not following the advice given by their colleagues in Dublin.

Ms Earley criticised the system which seemed to exist in Mullingar where there was “a fundamental breakdown” over who was responsible for the patient’s care.

She said such a system “can’t be acceptable or safe.”

Counsel for the Midland Regional Hospital in Mullingar, Caoimhe Daly BL, had called for a narrative verdict to reflect what she claimed was the complexity of the case as well as to explain how Ms Sainsbury had sustained her original injury.

She was supported by solicitor for Beaumont Hospital, Kevin Power, who claimed a finding of medical misadventure would be “a blunt tool” which could not encapsulate “the full picture.”

Earlier, Dr Gallagher observed that she had heard “diametrically opposite” evidence about who had responsibility for the care of Ms Sainsbury over the weekend she was in the hospital in Mullingar.

“There is a problem if two people each thought the other was in charge,” Dr Gallagher remarked.

A consultant surgeon on call in Mullingar at the time, Shahbaz Mansoor, gave evidence that Ms Sainsbury was not his patient but he was available to treat her if requested.

Prof Mansoor was adamant he would not interfere with the patients of other consultants as it would be “insulting,” although the inquest heard he had seen Ms Sainsbury during his rounds and believed her condition was deteriorating.

However, another consultant surgeon, Muhammad Majeed, under whose care Ms Sainsbury was admitted to the hospital, told the inquest on Wednesday that he expected Prof Mansoor would have been called about the patient if needed as he was off-duty over the weekend.

In reply to questions from the coroner, Dr Majeed said he believed the ultimate responsibility for the patient rested with the on-call consultant in Mullingar.

Returning a verdict of medical misadventure, Dr Gallagher noted that the deceased’s parents, Alison and Chris Sainsbury had raised concerns about their daughter’s condition throughout her stay in Mullingar as well as questioning why she was not being transferred to Beaumont.

She also acknowledged that a consultant neurosurgeon from Beaumont had assessed scans taken of Ms Sainsbury as showing her condition was deteriorating, while radiologists in Mullingar had interpreted them as indicating she was “stable.”

The coroner recommended that the Midland Regional Hospital in Mullingar should carry out a review of its on-call arrangements.

“It is clearly very important that staff know who to contact,” said Dr Gallagher.

Offering her condolences to Ms Sainsbury’s family, she said the inquest had been “very harrowing as is every day for you since this tragic incident.”

Welcoming the verdict, Bryonny’s mother said it had been a long while “fighting to get answers why our daughter died and why she didn’t get the adequate medical treatment that she should have had for the injury she sustained.”

“To find out two and a half years later that with a simple medical intervention she could still be here. You can’t put it into words – it's life changing,” she added.

“The doctors have got to listen to nurses and listen to the specialists,” said Ms Sainsbury.

Her husband said it was “tough” to find out for the first time at the inquest that their daughter’s life could have been saved.

Mr Sainsbury also called for additional on-call staff to be made available in hospitals over weekends.

The family, who were accompanied by their solicitor, Karen Clabby, said they would be taking further action over the circumstances of their daughter's death.