The case of Beata Kunicka from Kanturk, Co Cork who was “wrongly discharged” home has now led to changes in hospitals across the country
The High Court has heard that a mother, 33, passed away after Cork University Hospital overlooked the fact that she had swallowed her denture.
Hospitals around the nation have changed as a result of Beata Kunicka’s case in Kanturk, County Cork. She was “wrongly discharged” from the hospital. Cork University Hospital (CUH) expressed regret to Beata’s family “for the deficiencies in the care” that she received at the High Court on Friday.
Seventeen days after being released from the emergency room, Ms. Kunicka came back to CUH when she passed out at home and started throwing up blood. After the implanted denture was taken out of her oesophagus, she passed away on October 12, 2021, more than twenty hours later.
The HSE never disputed liability, according to the family’s attorney Gabriel Gavigan SC, who was hired by Tracey Solicitors. Additionally, the mediation process resulted in a €450,000 settlement for Ms. Kunicka’s partner Kamil Jarzembski’s proceedings.
On September 25, 2021, the young mother went to the hospital’s A&E for the first time. She complained of chest pain and said she thought she had just swallowed her denture, which consisted of two front teeth, a supportive pallet, and wiring.
In order to evaluate her ability to swallow, a tiny test meal was given to her and a plain film X-ray of her chest was scheduled. In addition, she was prescribed medications for her chest ache. But the X-ray revealed no foreign substance, and Ms. Kunicka—who was able to eat and drink was discharged.
Counsel said in a letter to Ms Kunicka’s partner Kamil Jarzembski last year, the hospital CEO David Donegan said an external review into the care of Ms Kunicka makes clear “that we failed to identify that her dental plate had indeed been swallowed and as such wrongly discharged her when she first presented to ED”.
Medical staff the letter said were not aware at the time that some denture plates will not show up on X-ray and “mistakenly decided that because she was able to eat and drink it was safe to discharge her.” It added that CUH has taken action to highlight these risks nationally to regulators and the HSE and amended its own local clinical training. Counsel said Ms Kunicka returned to CUH on October 12 after 1am.
She was not assessed in the ED until 7am and she was vomiting blood. It was ordered she be given blood and a CT scan was arranged. She collapsed again and later underwent surgery where the embedded denture was removed. However, she suffered severe bleeding and had to be again stabilised.
It was claimed that there was a delay in further treatment due to there being disagreement as regards the diagnosis and in the hours that followed there was prolonged discussion of the case.
Ms Kunicka became critically unstable and was haemorrhaging form her ear nose and mouth . She continued to deteriorate and went into shock and died from cardiac arrest after resuscitation efforts failed.
Counsel told the court the letter from the hospital CEO stated that the review also outlined the care of Ms Kunicka in the hospital when she returned there on October 12.
It said it was a complex and challenging presentation but “It is clear that a number of elements for care were not delivered promptly enough. Furthermore, clinical differences of opinion about the source for continued bleeding, the right course of corrective action and the availability of the necessary expertise to deliver it, all delayed her receiving the care she needed.”
Ms Justice Leonie Reynolds offered her condolences to Mr Jarzemnski and their young daughter Julia over “ the very tragic series of events” and she hoped they took some comfort from the review and that the recommendations have been shared nationally to ensure such an incident does not happen in an Irish hospital again
