By 
A CORONER has found that the death of Dromore woman, Triona McNabb, days after she was admitted to the South West Acute Hospital in Enniskillen almost nine years ago, was preventable.
The findings in the inquest into the death of the 34-year-old in 2017 were delivered by Coroner Maria Dougan at Laganside Courts in Belfast today.
During the almost two-hour closing of the inquest, Ms Dougan attributed the death of Miss McNabb to a bowel obstruction.
However, she concluded that on the balance of probabilities her death on February 27, 2017 was preventable.
The coroner said an early engagement with the gastroenterology team at Belfast City Hospital, where Miss McNabb had been treated for more than a decade and a transfer to there should have been considered.
She aded that the earlier involvement as well of an intensive care team for advice or alternative treatments could have resulted in Miss McNabb’s rapid deterioration being avoided and saved her life.
There were, the coroner added, a number of missed opportunities in the care and treatment of Miss McNabb, who was a popular member of the Dromore community, and a former player and coach with the St Dympna’s ladies team.
She added that that the medical team responsible for the care of Miss McNabb had ‘failed to adopt an holistic and proactive approach’ to her assessment and treatment.
Ms Dougan said there had not been ‘decisive clinical decision-making’ and there was insufficient consideration given to effective nutritional support, despite repeated recordings that she was malnourished.
She added that contact should have been made with the medical team who had previously treated Miss McNabb at Belfast City Hospital for background information and discussion about her treatment, management and possible transfer to the City Hospital.
There was also, according to the coroner, significant delays in reviewing and acting upon abnormal clinical findings test results, and that these delays had contribution to a deterioration in Miss McNabb’s condition.
She also found that there was an absence of adequate written documentation in respect of clinical decision-making and handovers, and that consideration should have been given to obtaining earlier input from the intensive care team at SWAH.
Witnesses at the Inquest included consultants and other medical staff who were involved in Miss McNabb’s treatment from the time she was admitted to SWAH until her death.
Ms Dougan expressed her heartfelt condolences to the McNabb family and paid tribute to them for the respect and patience which they had shown during the inquest, which she described as a ‘complex and difficult’ inquest into the death of Triona in tragic circumstances.
Legal representatives from the Western Trust have previously acknowledged deficiencies and accepted the findings of a Serious Adverse Incident investigation into the case.
