The inquest heard evidence from nursing staff about significant overcrowding and understaffing in the emergency department, which hindered urgent care for patients like Gary Crowley.
Coroner Clare Keane noted that Gary Crowley should have been prioritized for medical attention, but the use of two different triage systems resulted in confusion and misassessment.
Family members revealed that Gary, prior to his cardiac arrest, expressed feeling ignored and was in severe pain while waiting for adequate medical care at TUH.
Claire Crowley recounted how her brother felt unwell yet hesitated to inform their mother about his condition before he ended up in the hospital.
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