On February 10, 2025, at the Dublin District Coroner’s Court, a verdict of medical misadventure was delivered in the case of Derek O’Neill, a 53-year-old who tragically lost his life due to the failure to administer prescribed anticoagulants to treat blood clots. This case has placed the term medical misadventure under renewed scrutiny, drawing attention to the implications for both patient safety advocates and medical professionals.
This blog explores O’Neill’s case, the broader implications of the term medical misadventure, and what it means for ensuring accountability and reform in Ireland’s healthcare system.
The Tragic Case of Derek O’Neill
On October 22, 2022, Derek O’Neill attended St Vincent’s University Hospital with breathing difficulties and chest pain—a condition that had worsened over four weeks. A CT pulmonary angiogram later revealed bilateral pulmonary emboli (blood clots in both lungs). This life-threatening condition required prompt medical intervention, including anticoagulation therapy with Tinzaparin, which was outlined in his treatment plan at 4.45 pm.
However, a devastating series of oversights occurred:
- The anticoagulant was not prescribed until approximately 9 pm.
- Despite the prescription, the medication was never administered.
Shortly before 11 pm, Mr O’Neill became unresponsive. Resuscitation attempts, including thrombolysis to dissolve the clots, were unsuccessful, and he passed away after midnight on October 23, 2022.
The inquest culminated in a verdict of medical misadventure, with Coroner Dr Claire Keane highlighting critical delays in administering life-saving treatment. Dr Keane endorsed procedural recommendations made by the hospital, including additional staff education on managing suspected pulmonary embolisms and improving communication regarding potentially fatal conditions.
What Does “Medical Misadventure” Mean?
The term medical misadventure is commonly misunderstood to imply fault or negligence, yet its legal definition is more nuanced.
According to Dr Denis McCauley, a Donegal Coroner, medical misadventure signifies death while under medical care and does not assign blame or liability. This differs markedly from the public perception, which often assumes fault lies with medical professionals. For this reason, some experts advocate for a more neutral term, such as death while under medical care.
Other Possible Verdicts
The verdict of medical misadventure sits alongside a range of recorded outcomes in Ireland’s coronial inquests, including:
- Natural causes
- Accidental death
- Suicide
- Unlawful killing
- Open verdict (when the cause of death remains unclear).
Importantly, an inquest does not establish criminal or civil liability but exists solely to uncover facts about how, when, and where a person died.
The Impact of Medical Misadventure Verdicts
While the term medical misadventure avoids overt accusation, it remains controversial due to its potential to sow misinterpretation and mistrust. Families often seek closure and justice through an inquest; however, the wording of verdicts can shape how fault—or the absence thereof—is perceived.
For medical professionals, a medical misadventure verdict may expose them to unwarranted blame, hindering a culture of learning from mistakes. For example, in complex cases such as high-risk surgeries or emergency interventions, outcomes may not reflect the diligence or effort of healthcare providers.
Calls for Change in Ireland’s Coroner Process
Discussions surrounding Derek O’Neill’s case and broader issues within Ireland’s coroner process bolster the case for reform. Current challenges include:
- Delays in performing post-mortems or issuing coroner findings, which exacerbate grief for bereaved families.
- A lack of clarity in verdict terminology, leading to potential confusion and stigma.
- Insufficient systemic focus on preventative measures post-inquest.
The establishment of an Office of Chief Coroner, as proposed in recommended reforms, could unify standards and improve the efficiency of Ireland’s Coroner Service. Additionally, a review of terminology—such as replacing medical misadventure with a descriptive term like death under medical care—could promote transparency and reduce misunderstandings.
What Can Be Done to Prevent Further Tragedies?
From medical professionals to patient safety advocates, several key steps can be taken to prevent future cases like Derek O’Neill’s.
For Healthcare Systems:
- Early Intervention Protocols: Hospitals should implement robust systems to catch delays in administering urgent treatments.
- Education and Communication: Regular training on managing high-risk conditions, such as pulmonary embolisms, and ensuring seamless communication between staff are vital.
- Accountability via Reviews: Post-event reviews should track systemic flaws and enforce real changes.
For Families:
- Stay Empowered: Families of patients can demand to be informed about treatment plans and outcomes at every stage.
- Pursue Support: Advocacy groups and legal professionals can help families access representation during inquest proceedings.
Legislative Change:
Ongoing campaigns to reform laws, including those addressing coronial processes in maternal and neonatal deaths, must remain a priority. Such changes ensure that accountability stretches beyond individuals to examine systemic weaknesses.
The Road Ahead
The case of Derek O’Neill highlights systemic flaws that extend far beyond the corridors of St Vincent’s University Hospital. For families, inquest findings like medical misadventure are often both illuminating and frustrating, recognising harm but falling short of delivering accountability. For healthcare providers, it represents a balance between openness and the fear of undue blame.
Change is essential—not only in how medical failures are described but also in how healthcare systems, legislation, and society approach accountability and learning. Death under medical care should be viewed as an opportunity to understand systemic weaknesses and instigate tangible reforms.
At moments when tragedy strikes, the affected families deserve clear processes, honest answers, and meaningful reforms. By addressing these systemic flaws, we can protect future patients and ensure that no life lost is overshadowed by avoidable mistakes.
