Teacher 'might have survived op had medics communicated better'
A popular teacher who died from a rare complication after surgery might have survived had doctors "communicated better" and ordered a heart scan sooner, a coroner has said.
The findings were made yesterday by Coroner Joe McCrisken at the inquest of father-of-one Martin Beare, which was held at Laganside Court in Belfast.
The coroner said he believed that at the time of the incident, "staff did not escalate concerns quickly enough".
Described as "a kind and loving husband, father and brother who was completely devoted to his family" by Sinead, his wife of 23 years, Mr Beare from Dunmurry suffered from arrhythmia - an irregular heartbeat.
The Maths teacher had retired four years ago to care for his daughter Caoimhe and had consented to the elective surgery at Belfast's Royal Victoria Hospital in June 2013 to improve his quality of life.
The court heard that although the procedure was carried out several times privately, Mr Beare (55) was the first in Northern Ireland to be offered a Pulmonary Vein Isolation on the NHS.
A teacher of 32 years experience, Mr Beare had worked at Belfast's St Louise's Comprehensive. Initially, he was offered the surgery at a hospital in Leicester to help with the symptoms of his condition, which included light-headedness and which would occur unpredictably.
However, funding was allocated for surgery in Belfast and he was admitted on Saturday June 29 for an overnight stay. The court heard how Mr Beare left theatre at 1.30pm, where he had had a scan with the medical catheters still in his heart. His blood pressure continued to drop while his heart rate increased and he remained "groggy".
His medical notes recorded several declines in his blood pressure but another scan to check his heart was not deemed necessary until after 8.30pm where his condition had deteriorated to being "gravely ill".
Blood from the surgery had oozed into the pericardium, the sac that surrounds the heart. The condition, pericardial effusion, had put strain on his heart.
As doctors inserted a drain, he went into cardiac arrest for 10 minutes, causing loss of oxygen to his brain, and requiring resuscitation. He was moved to intensive care where he died on July 2.
Mr McCrisken heard how a scan of the heart called an echocardiogram, would have highlighted the problem sooner but it did not take place until more than eight hours after surgery.
A total of 11 medical staff - including consultant cardiologists, a heart surgeon, a junior doctor and a nurse - were called to give evidence at the hearing, which heard that a pericardial effusion was a rare complication of such surgery - 45 out of 28,000 operations worldwide.
But lessons had been learnt from Mr Beare's death, the court heard, and Belfast Trust had since implemented a number of recommendations to prevent such an incident again.
These included a postponement of such procedures for nine months; that they would no longer take place at the weekend when there were fewer consultants around; that general anaesthetic would be used; that all patients would be nursed in the Coronary Care Unit instead of a regular ward and the process of taking concerns over a patient to a senior doctor made easier.
All patients would also undergo three echocardiograms including when medical catheters are removed from the heart and just before discharge.
Mr Crisken found that Mr Beare's "outcome might have been affected had a scan taken place sooner".
He said: "Mr Beare was a teacher with responsibility toward his students.
"The medical staff concerned in this case had a responsibility towards him and it is a responsibility, when someone places their life in your hands, that cannot be taken lightly.
"I am satisfied that there were a number of failings in his care but recognise that there were also good examples of care also with swift action being taken once the problem was identified.
"The echocardiogram should have been performed much sooner with the catheters removed and the registrar should have been made aware of his presence on the ward."
Mr Beare's liver was donated to a 23-year-old man and his other organs donated to medical research, which Mr McCrisken commended the family for.