Family welcomes verdict of medical misadventure in Offaly man's death

THE FAMILY of a man who died from a catastrophic bleed while working in Limerick, “really hope that another family never has to go through what we have over the past two years and eight months.”

Speaking after the two-day inquest at Kilmallock District Court, the late Jimmy Lowry’s son James said: “Dad was taken from us far too soon and we came here this week to find the truth. We welcome the verdict of medical misadventure and the recommendation for improved communications in the systems at work in University Hospital Galway that came from the court.”

Jimmy Lowry, who was aged 65 and from Ferbane, County Offaly, was the uncle of professional golfer Shane Lowry.

Jimmy Lowry, who was an avid GAA club man, was doing a delivery in Limerick when he suffered the fatal bleed.

He has been described as a “strong, hard-working” family man, who was generous and someone you could rely on, yet, his family told the inquest, that when it came to it, Mr Lowry could not rely on and depend on the health system to save his life.

Mr Lowry had suffered from a complex kidney issue and had been undergoing dialysis for 13 years prior to his death.

Mr Lowry’s family told the inquest that despite his serious health concerns, he was never afraid of anything, but after two major bleeds, he was in perpetual fear of another bleed.

On the day Mr Lowry died when delivering to a Limerick business, a witness told the court that there was so much blood that he asked for a tipper skip, which would hold up to 600 litres of water, to wash it away.

University Hospital Galway apologised for the “systems failures related to the care and service issues” provided to Mr Lowry. His death has prompted the hospital to change pathways and access to vascular services.

Mr Lowry’s family solicitor confirmed that civil court proceedings will follow.

His wife Alice described her late husband as being “always ready and willing to help out everyone and give of his time. Jimmy was hard-working, determined, quiet and assertive. He was also the chairman of the local GAA club for two terms and was someone who liked to get things done. You could depend on him. He was someone you could rely on. He was a family man who never drank or smoked."

The inquest heard that medical professionals were aware of an urgent need to repair a dormant arteriovenous (AV) fistula, which had previously been used for dialysis.

An AV fistula was surgically created to link an artery and vein for use in dialysis, but Mr Lowry’s was not being used, due to it deteriorating and the risk of a bleed.

Representing the family, solicitor and partner at Callan Tansey in their Limerick office, Scarlett O’Sullivan told the Limerick Leader outside the courthouse that:  “He suffered from Iga nephropathy [a disease causing kidney inflammation], meaning that he had to have an AV fistula inserted in 2013 for hemodialysis.

“This started to cause problems in May, 2022, and there were a number of missed opportunities by his medical attendants to avoid a catastrophic bleed. He suffered from two spontaneous bleeds in June and October of 2022, when his son James was in a position to apply a tourniquet and stop the bleed [he was a sub-station office for the fire service]. There were a number of red flags and missed opportunities to ligate and surgically repair Jimmy's AV fistula. If that intervention had been made, he would not have suffered a catastrophic and foreseeable bleed and died.”.

Mr Lowry was on an urgent list to have the AV fistula repaired, and on the Monday before he died, he told Nurse Lorna Durack: “If someone doesn’t do something about my arm, you will be coming to Alice with a Mass card”.

Mrs Lowry told the court: “As Lorna said to me at Jimmy’s wake, ‘little did I know that four days later I would be here at Jimmy’s home with a Mass card at his wake’.”

She added: “We have been robbed of the biggest treasure that we had. To make it worse, Jimmy died without getting the chance to speak to any of his family. We never even got a chance to say goodbye as he was dead before we arrived at the hospital. My husband died without any of his family by his side. We will never forget the shock and trauma of being told in A&E that he had passed away.”

Mr Lowry died at University Hospital Limerick on Thursday, February 23, 2023. The inquest heard that just two months before he died, Mr Lowry presented to the ED at University Hospital Galway with a letter saying his fistula “is a very big risk for massive bleeding”, but this letter was not seen by the emergency registrar and he was sent home.

In delivering his verdict, coroner John McNamara said: “Communication can always be better, I don't think it’s good enough that a letter is brought to the hospital and it's not handed into the doctor.”

Dr David Lappin agreed with Mr Roger Murray, who was representing the Lowry family, that on the balance of probabilities, if the fistula had been dealt with in a satisfactory way that the catastrophic bleed, which caused Mr Lowry’s death, would likely not have happened.

Mrs Lowry told the inquest that her husband had been under the care of Dr David Lappin in Merlin Park Hospital, he had a good relationship with him and was very happy under his care “up until the week he died.”

Professor Sherif Sultan told the inquest that the doctors are frustrated by the system failures in the Galway hospital. He said: “We had an external review to see what we are doing every day and that's the reply that you got from external review; you need more manpower, you need more structure. I cannot create theatre space, it is beyond my limitation. I am here to fly an aeroplane. If there is no aeroplane and no runway, I cannot fly. Currently, we have a major problem.”

The cause of death was deemed to be post-hemorrhagic shock, which is severe blood loss.

The coroner noted that: “At the heart of every inquest, a family has suffered. It's clear that Jimmy was much-loved and had a very strong bond with all of his family. He sounds like a man you'd love to go for a pint with, even though he didn't drink.”

Jimmy Lowry is survived by his wife Alice, sons Brian and James, daughter Jennifer, five grandchildren and a wide circle of extended family, neighbours and friends. May he rest in peace.

READ NEXT: New two-storey building approved for Offaly School of Special Education in Tullamore

READ NEXT: 'Huge achievement' for an Offaly man from a humble background