The Health Service Executive (HSE) has admitted a breach of duty following the death of 71-year-old PJ O’Connor, a Tipperary farmer who died nine days after receiving substandard care at University Hospital Limerick (UHL). The High Court heard that a radiologist missed a brain bleed on a CT scan read remotely in the early hours of November 27, 2021, leading to the administration of contraindicated treatment. The HSE further acknowledged that a four-hour delay in arranging an ambulance for his transfer to a Cork hospital contributed to his death.
Did You Know? The reporting radiologist suggested the brain bleed may have been missed because the scan was assessed in the “brain soft tissue window” rather than the “head bleed window,” a step the radiologist admitted he may have failed to perform.
How the medical and administrative failures occurred
According to counsel for the family, Patrick Treacy, Mr. O’Connor was admitted to UHL on November 26, 2021, presenting with a right facial droop. A CT scan was performed after 2:00 a.m. and read by an outsourced radiologist at 2:30 a.m. Due to the failure to identify the bleed, Mr. O’Connor was incorrectly treated with medication intended to dissolve blood clots. When his condition worsened, a transfer to a neurosurgical unit in Cork was required. A call review report cited “significant challenges” with ambulance availability, resulting in a four-hour wait for transport after the booking was made at 11:30 a.m.
The legal resolution and family response
The O’Connor family settled their High Court action on Thursday, during which a letter of apology from the HSE was read into the record. Signed by Ian Carter, chief executive of HSE Mid West Acute and Older People Services, the letter stated that the care provided “fell below our standards and best practice.” Outside the Four Courts, the victim’s son, James O’Connor, described the legal process as a long battle that “prolonged our grief.” His sister, Katherine Kirby, stated the family pursued the case to highlight systemic failings so that other families might be spared similar experiences.
Expert Insight: Understanding the implications of outsourced diagnostics
The reliance on outsourced, out-of-hours radiological reporting represents a significant operational shift in modern hospital care. While such models are designed to provide 24/7 coverage, this case highlights the critical risks involved when remote clinicians face distractions or technical omissions—such as failing to toggle between specialized viewing windows. The incident suggests that the integration of external services into acute hospital pathways requires rigorous oversight to ensure that the speed of a remote report does not come at the cost of diagnostic accuracy or patient safety.
Following the court’s approval of the €35,000 statutory mental distress payment, it is possible that the HSE will face increased scrutiny regarding its reliance on third-party diagnostic services and the persistent issue of ambulance availability. Analysts might expect that the O’Connor family’s public call for accountability will place additional pressure on the health service to review its emergency transfer protocols and the quality control measures applied to outsourced medical reports.
Frequently Asked Questions
Why did the radiologist miss the brain bleed?
According to statements made in court, the radiologist suggested he may have assessed the scan using the brain soft tissue window and failed to perform the necessary head bleed window step, potentially due to the time of night or distraction by the appearance of the patient’s vertebral arteries.
What did the HSE admit in its apology?
The HSE admitted a breach of duty regarding the failure of its radiology services to detect the bleed, the administration of contraindicated treatment, and a delay in providing timely ambulance transport and appropriate reversal treatment, which it acknowledged caused Mr. O’Connor’s death.
What caused the delay in the patient’s transfer?
A call review report indicated that the four-hour delay between the 11:30 a.m. ambulance booking and its 3:30 p.m. arrival was caused by significant challenges with emergency ambulance availability, driven by high service-level demand and hospital delays.
How can health authorities ensure that outsourced medical services meet the same standard of care as in-house departments?
