The Dublin City Coroner's Court has returned a verdict of medical misadventure on the final day of the inquest into the death of a two-year-old haemophiliac at Our Lady's Hospital for Sick Children in Crumlin.
Pierce Nowlan of Carrickmore Green, Saggart, Co Dublin, had an artery punctured during an operation which was - according to one consultant - supposed to transform his life.
Medical misadventure is the unintended result of an intended action.
The Dublin City Coroner, Dr Brian Farrell, said it was a neutral verdict. He was making no judgment in what he perceived as a breakdown between surgeons and anaesthetist.
The inquest heard how the boy had been suffering more bleeds as he become more mobile and was a high mortality risk.
The operation to fit a device into one of his veins was described as 'life-transforming'. However, an artery on the left side of his chest was punctured during the procedure.
Surgeons then performed open surgery, attaching a device to a vein in his neck.
Pierce Nowlan was then taken to the recovery room where his blood pressure and heart rate were said to be normal and he was described as being of stable condition.
It was only in the following hours tests and X-rays confirmed that Pierce had suffered considerable internal bleeding of his chest which led to a cardiac arrest later that night.
He died three days later on 14 October 2004.
According to the Nowlans legal team, the inquest centred on conflicting and contradictory evidence which only came to light as a result of Steven and Jean Nowlan getting an amendment to the Coroner's Act, allowing for more than two medical practitioners to give evidence at an inquest.
