‘Myself, the GP and the system let the family down’ – consultant

A hospital consultant has apologised to the relatives of a Dublin woman who died from a toxic side-effect of a drug prescribed to treat her latent tuberculosis stating: “Myself, the GP and the system let the family down”, writes Seán McCárthaigh.

A verdict of medical misadventure was recorded into the death of Dymphna Dykes (68) of Virgin Heights, Springfield, Tallaght at St Vincent’s University Hospital on March 26, 2021.

The results of a postmortem showed that the married mother of two, who came originally from Carrick-on-Suir, Co Tipperary, had died from multi-organ failure due to acute liver failure linked to the toxic effect of a drug, Isoniazid.

A sitting of Dublin District Coroner’s Court heard evidence that monthly liver function tests that had been recommended after Ms Dykes had been given a six-month prescription for Isoniazid to treat her latent TB were not carried out.

The inquest heard that Ms Dykes had completed the course of Isoniazid two weeks before she presented at TUH on February 24, 2021 where she was diagnosed with severe liver malfunction before being transferred to St Vincent’s University Hospital where it was decided that she was not suitable for an urgent liver transplant.

A consultant hepatologist at TUH, Niall Breslin, said he believed it was most likely that the liver damage to the patient would have started in the first few months of taking Isoniazid.

A consultant in respiratory medicine who treated Ms Dykes at TUH, Seamas Donnelly, said Isoniazid was the standard first option treatment for a patient with latent TB.

The inquest heard that Prof Donnelly, after prescribing the drug for Ms Dykes, had written to her GP, Siobhan Kierans, of Tallaght Medical Centre on August 25, 2020 to check if she would arrange monthly liver function tests in order to monitor the patient for any side-effects of Isoniazid or whether they should be done at TUH.

Prof Donnelly said he never got any response from the GP  but had inferred that Dr Kierans was arranging the tests as there was no evidence to the contrary.

He observed that it was not possible to have “a 100 per cent failsafe system within the health services at the moment” to ensure he became aware of recommended monthly test results.

While the consultant saw Ms Dykes in October 2020 after she had just started taking Isoniazid for a few weeks, he said the patient had cancelled another appointment in December 2020 due to a family bereavement before he saw her again in February 2021.

However, Prof Donnelly said no red flag was ever raised on the patient’s file over that period.

Under cross-examination by counsel for the deceased’s family, William Reidy BL, the consultant said he had been reassured when Ms Dykes had told him that she had tests after Christmas without realising it was a reference to ordinary blood tests.

Asked if there had been any changes at TUH since Ms Dykes’ death, Prof Donnelly said he now personally asked GPs to confirm they were carrying out such tests if he did not get a response from them.

However, he added: “It’s not a perfect system.”

Prof Donnelly accepted that there was an opportunity to have clarified with Ms Dykes if she was having the liver function tests when he reviewed her in October 2020.

Apologising to Ms Dykes’ husband, Freddie and the couple’s two daughters, Kerena and Aiveen, Prof Donnelly said: “Myself, the GP and the system let the family down.”

In evidence, Dr Kierans admitted that she could not recall reading the letter in full from Prof Donnelly seeking clarity about who would carry out the recommended monthly liver function tests after Ms Dykes had been prescribed Isoniazid.

Dr Kierans, who is no longer practising, admitted it had “gone under the radar.”

“It was a bit stupid of me,” she added.

The GP did not recall if Ms Dykes had ever mentioned to her that she needed her liver tested.

Dr Kierans admitted she did not have enough knowledge about Isoniazid and was unaware of the need to monitor patients using the drug.

She also accepted that she had not asked Ms Dykes about having a liver function test when she saw her in October 2020.

Asked by Mr Reidy if there was a lack of system in her practice, Dr Kierans replied: “I agree. There is a lack of system in a lot of things.”

A pathologist, Niamh Nolan, told the hearing that the effects of the drug had caused a widespread loss of liver tissue which has resulted in the deceased’s liver weighing 390g compared to the expected normal weight of 1,500g.

Dr Nolan said such a side-effect of Isoniazid was rare but well recognised and was known to affect 1% of patients.

At the end of the evidence, Mr Reidy called for a verdict of medical misadventure on the basis there was no follow-up to ensure Ms Dykes underwent monthly liver function tests.

Mr Reidy pointed out that two doctors each believed the other was taking care of the tests in what was “a communications issue.”

He said it was “deeply worrying” that the patient’s GP had not read the letter sent to her by Prof Donnelly in full.

Mr Reidy said there was no system in place to direct who was responsible for ensuring tests were carried out to act as a “safety net.”

He observed there were also multiple missed opportunities to have checked if Ms Dykes was having the recommended tests.

Counsel for Prof Donnelly, Rory White SC, called for a narrative verdict as he claimed one of medical misadventure would “not do justice to the complexity of the evidence.”

His submission was supported by counsel for Dr Kierans, Padraic Hogan, BL.

Returning a verdict of medical misadventure, coroner Cróna Gallagher said recommended monthly tests to monitor Ms Dykes were not performed during her six months of taking Isoniazid.

Dr Gallagher stressed that it was “a neutral verdict” to reflect the fact that Ms Dykes’ death was the unintended consequence of a medical treatment.

The coroner said she could not think of any “coherent, actionable” recommendations that she could make that would specifically address issues raised during the inquest.

However, she noted that there had been learnings from the case particularly in relation to communications between doctors.

Following the inquest, solicitor for the Dykes’ family, Aidan Flahavan, said they welcomed the verdict and hoped that lessons would be learned although no recommendations had been made.