Cork woman (33) died after CUH X-ray failed to find denture she swallowed

A 33-year-old mother died after Cork University Hospital, when she first presented to the emergency department failed to detect that she had swallowed her denture, the High Court has heard.

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 today heard Cork University Hospital (CUH) has apologised to her family “for the deficiencies in the care” provided to Beata.

Ms Kunicka had returned to CUH seventeen days after first being discharged from the emergency department, when she collapsed at home and was vomiting blood. She died over twenty hours later on October 12, 2021, and hours after the embedded denture was removed from her oesophagus.

The family’s counsel Gabriel Gavigan SC instructed by Tracey Solicitors told the court that liability was never contested by the HSE and the proceedings brought by Ms Kunicka’s partner Kamil Jarzembski were settled for €450,000 after mediation.

The young mother first went to the hospital A&E on September 25, 2021, complaining of chest pain and reporting that she believed she had recently swallowed her denture which was two front teeth , supportive pallet and wiring.

A plain film X-ray of her chest was arranged, and she was given a small test meal to assess her ability to swallow. She was also given painkillers to treat her chest pain.

However, no foreign body showed up on the X-ray and Ms Kunicka, who was able to eat and drink was discharged.

LETTER

Counsel told the court 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.