This tragic death of the late Denisse Danco remains for the time being a medical mystery.
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This tragic death of the late Denisse Danco remains for the time being a medical mystery.
Irish Examiner, Friday. Febr., 02,2018
Open verdict returned as cause of Cork student’s death unknown
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The distraught parents of a healthy 20-year-old student who died suddenly in a hospital emergency department (ED) still do not know why their daughter died following an inquest.
Unfortunately for Mary and Carlos Dasco, the death of Denisse Kyle Dasco, who had “no significant medical history”, falls within the 5% of cases where there is “no absolute diagnosis”.
Despite in-depth analysis of tissue from the deceased by multiple experts at home and abroad, assistant state pathologist Margot Bolster said the cause of death was “unascertained”.
Sudden arrhythmic death, pulmonary embolism (clot in the lung) and toxic shock were considered on foot of expert reviews but Dr Bolster said as far as she was concerned the cause of death was not determined and she was “only speculating on the other three”.
“It’s very unfortunate that we cannot pinpoint the cause of death,” she said. “This case is just so unusual.”
The inquest heard that Denisse Kyle Dasco, who was originally from the Philippines but whose family home was in Limerick, texted her friend Chyna De Los Angeles at 6.35am on April 21, 2017, asking for help because her blood sugar levels were low.
Ms De Los Angeles told the inquest she arrived at Denisse’s accommodation — 27 Woodside Quay, Hanover St, Cork — after 9am. She had to wait for a bus and stopped off at Tesco to buy her friend Lucozade.
On arrival, Ms Dasco was lying on the bed with a pain in her back and “couldn’t get comfortable”. She had taken paracetamol.
Ms Dasco had been in pain since the previous night, when she bent down to pick something off the floor while at work in a restaurant. She had woken up in pain at 2am. The two women decided to call an ambulance and Ms Dasco phoned her mother, who lives in Limerick.
Ms De Los Angeles said Ms Dasco, a third-year forensic science student at University College Cork, had to be helped to walk to the ambulance “the pain in her back was so bad”. “She told me she had never felt that kind of pain before,” Ms De Los Angeles said.
On arrival at the Mercy University Hospital (MUH) c10am, Ms Dasco told the doctor she had a “sharp and throbbing” pain radiating down her leg.
Dr Eoin Moriarty told the inquest Ms Dasco had no significant medical history and there were “no signs suggestive of deep vein thrombosis” (DVT, a deep vein blood clot in the lower leg or thigh). Ms Dasco had flown to and from Barcelona, a two-hour flight, on April 10 and 15. Air travel can pose a risk of DVT.
In order to rule out a clot, Ms Dasco underwent a D-dimar test. The result was not conclusive so Ms Dasco underwent an ultrasound. There was no evidence of DVT in her lower limb. Because she remained in pain, Dr Moriarty said he was “not content” to discharge her.
Asked by the coroner, Philip Comyn, what his differential diagnosis was, Dr Moriarty said that, in light of the pain in her left buttock, he believed Ms Dasco had sustained a mild musculo-skeletal injury while bending down.
Dr Moriarty had gone off duty at 8pm — he had handed Ms Dasco’s case over to the on-call medical team at around 5pm — and upon returning for duty the next day he learned of her demise. His reaction was one of “disbelief”, he said.
The medical team had assessed Ms Dasco. There was no history of lung clots or DVT in her family. Musculo-skeletal hip pain unrelated to DVT was considered. Nonetheless in light of the ongoing pain, she was scheduled to have an MRI the following day. By 8.30pm, Ms Dasco was sleepy, but had no other complaints, the inquest heard.
The situation changed when she went to the toilet with a staff nurse at 9.30pm. She complained of pins and needles in her leg “and was acutely short of breath”.
She was moved into a cubicle. She began coughing blood.
There was rapid loss of consciousness. She suffered a cardiac arrest at 10pm and full life support started. Dr Gemma Browne, the on-call anaesthetist, said when she arrived at the resuscitation room at 10.15pm, there was “no obvious sign of life” and there were “copious bloody secretions” coming up the endotracheal tube.
Hospital staff spent 40 minutes trying to resuscitate Ms Dasco. Her death was confirmed at 10.40pm. Her mother, who was travelling down from Limerick, did not get to see her daughter before she died.
Emergency medicine consultant at MUH, Dr Adrian Murphy, gave an overview of what happened to Ms Dasco at the inquest, although he was not in attendance on the day in question. While Ms Dasco’s vital signs had fluctuated during the day, these changes were not of concern “in isolation” he said.
Her vital signs had been checked regularly and she was given painkillers for moderate pain. When examined on arrival at the ED, there was no sign of numbness, no known drug allergies, no significant past medical history and she had never before experienced that kind of pain.
The power was reduced in her left leg, but there was no swelling.
There was no evidence of DVT above the knee, but the pain got worse with any change of position.
Staff at MUH use an early warning system (EWS) with a range of one to 21 and certain actions are supposed to be taken once the score starts to rise. Ms Dasco’s EWS was one at 5.30pm but had risen to nine by 9pm.
It dropped back to six subsequent to that. However, she “deteriorated significantly” around 9.45pm.
“After being helped to the toilet, she had pins and needles in her lower limbs and nausea and breathlessness,” Dr Murphy said.
He said “something catastrophic happened in or around 9.45pm” and staff swung into full emergency mode. Unfortunately, nothing could be done for Ms Dasco.
Dr Murphy said that, in 15 years of clinical practice, he had never encountered a case like Ms Dasco’s. Even with the benefit of hindsight, he could not say what he would have done differently, he said.
“I’ve reviewed all of this and I can’t think of anything I would have done differently that would have changed the trajectory of the outcome,” he said.
Dr Bolster said it was “a complex case and multiple experts were consulted”.
She said that no ethanol (alcohol) was detected in Ms Dasco’s system and no drugs other than therapeutic medication.
She said an “usual feature” of the case was the “relatively advanced state of decomposition of the body” when she conducted her inquest on April 24.
Dr Bolster said consultant histopathologist Prof Sebastian Lucas at Guy’s, King’s and St Thomas’ Hospital in London, had reviewed the whole case and considered the possibility of sudden arrhythmic death once pulmonary embolism was excluded. Also the possibility of sepsis, “or what we call toxic shock” Dr Bolster said, was considered but each was “only a possibility”.
Barrister Colmán Ó Donnchadha, for the Dasco family, asked if Dr Bolster was saying there were three possibilities, but Dr Bolster said: “My cause of death is unascertained. I’m only speculating on the other three.”
Mr Comyn said he was recording an “open verdict” in the case of the death of Ms Dasco, of 47 Russell Court, Fr Russell Rd, Raheen, Limerick. He extended his sympathy to the family on foot of this “very sudden and tragic death”.
Ms Dasco’s family made no comment to the media and asked that their privacy be respected.
They previously raised concerns about the lack of information forthcoming from MUH, but Mr Comyn said this was because his coronial investigation was under way and he wanted to avoid any incorrect information being given out that might cause “additional upset”.