The High Court found Beaumont Hospital and surgeon Professor Michael Walsh negligent after a newly inserted tracheostomy tube became displaced and Alfred Gottstein suffered fatal brain damage. The judgment said an appropriately trained person should have been in intensive care or immediately available to replace the tube.
Mr Justice Johnson delivered the judgment on 21 December 2004 in a case brought by Mr Gottstein’s widow, Una Gottstein. The operation to remove cancer from Mr Gottstein’s throat was carried out skilfully, the court said, and the plaintiff did not allege that the nurses or doctors made a clinical error in their immediate care.
Mr Gottstein was in intensive care after the operation. On the evening of 8 September 1992, he reported chest discomfort. When Nurse Harrington later tried to suction the tracheostomy, she met resistance and called for help. Nurses and doctors attempted to restore his airway. Dr O’Connor eventually secured oral access, but the judgment said Mr Gottstein had become brain dead before an airway was established.
The plaintiff’s case focused on the absence of staff trained to replace a displaced tracheostomy tube. The judge accepted evidence from the plaintiff’s medical witnesses that displacement can occur and requires an immediate response. He also referred to medical literature describing accidental removal as a recognised, not uncommon event, and to a hospital document that discussed what to do if a tube fell out.
The court found Beaumont Hospital negligent for failing to have a suitably skilled person in intensive care or immediately available in the hospital. On the balance of probabilities, the judge found that Mr Gottstein would not have died if such a person had been present. He also held Professor Walsh negligent, reasoning that his overall responsibility for the patient made him legally responsible for the failure to provide appropriate intensive-care support, despite the unit’s separate management by anaesthetists.
The judgment records findings of negligence against both defendants. The supplied text does not state a damages award or other final order.