The HSE has apologised to the family of a five-year-old girl who died as a result of medical misadventure at Sligo University Hospital (SUH) more than two years ago.
The inquest of Kate Colum from Strokestown, Co Roscommon, heard that she died following a severe acute Strep A infection with organ dysfunction consistent with sepsis and or strep toxic shock as a major contributing factor.
Following the inquest, Kate's parents Claire and Matthew Colum said they were thankful for the outcome.
They said while the verdict didn’t bring back their daughter, it closed a door that would hopefully allow them to remember Kate as "the little girl she was".
"Kate’s smile was infectious, her laugh, her love farming with the boys, her love of bottle feeding the sheep, the trampoline, chocolate buttons, colouring and watching Peppa Pig," they said.
They added: "She led a very full life with playschool, dancing on a Friday, farming all the rest of the time.
"As one door closes another opens and we're bringing Kate's memory forward".
"The reason this child is dead is because she was discharged from the hospital when she should not have been"
The Colum family have agreed to work with the HSE on future training for medical professionals when dealing with children with down syndrome and additional needs.
Kate Colum was admitted to SUH by ambulance on Wednesday 29 March 2023, discharged later, and readmitted by ambulance on the following Friday.
Barrister Keith O’Grady, who was instructed by Solicitor Niamh McGovern on behalf of the Colum family told the inquest that Kate Colum "should never have been discharged from SUH on the morning of Thursday 30 March 2023"
"The reason this child is dead is because she was discharged from the hospital when she should not have been.
"This girl (Kate Colum) lived a very full life. These two people (Claire and Matthew Colum) want to make sure this never happens again and that other people benefit from the death of their daughter that should be here".
'Kate's life was a blessing, her memory a treasure' say parents after HSE apology
The medical professionals who provided depositions provided accounts of Kate Colum’s treatment at the hospital in the final days before her death.
Senior Counsel Luan Ó Braonáin, instructed by Solicitor Declan Hegarty on behalf of the HSE apologised to the Colum family on behalf of SUH management and staff.
He said they offered a sincere apology and regretted the suffering and grief they experienced as a result of shortcomings in the care of their daughter.
He said they are committed to progressing the recommendation that similar situations won’t be experienced by other patients.
Ms Colum told the inquest that recommended that her daughter was so healthy and that Down Syndrome did not affect her health at all.
She described how Kate became unwell on the Monday before she was first admitted to the hospital.
She said Kate’s temperature reached 40.1 degrees on Wednesday 29 March 2023 and that she called 999 at 8.46pm that evening.
The inquest heard Kate presented to the hospital with symptoms including a high temperature and vomiting on Wednesday night.
Ms Colum described the medical assessment her daughter received. She said a medical professional told her that although Kate had a significant virus - she advised taking her home and added that she would be fine at home.
"I feel so let down and disappointed in the way that Kate was treated by medical professionals. They let us down"
Ms Colum said she asked about blood tests and a urine sample but was informed that it was not necessary. She said she trusted the medical advice at the time.
Both Claire and Matthew Colum remarked at the inquest on how Kate became more unwell on Thursday night after being discharged.
In the early hours of Friday morning, she was readmitted with a persistently high temperature, decreased oral intake, irritability and decreased urine.
Ms Colum called for an ambulance at 1.42am on Friday morning. She described the final hours of her daughter's life at SUH before she passed away at 8.50am.
Ms Colum said that the "diagnosis of sepsis took far too long" and added they "never left Kate and witnessed everything" as she detailed inaccuracies in the hospital’s record of Kate’s treatment.
Kate’s father said his daughter should never have been let home that first night and added that his daughter "paid the ultimate price".
"I feel so let down and disappointed in the way that Kate was treated by medical professionals. They let us down," he said.
He said his daughter loved to farm with him in all types of weather and added "she had a very good immune system".
Ms Colum said her daughter was a great little girl who went to mainstream playschool with no support and she "farmed full time" with her father.
She described Kate’s love of chocolate buttons and jigsaws. She said the inquest was a long time coming and added that they can close the door and get back to remembering Kate.
"We’re going to bring her forward with us… we want to take a positive from this. We want to create an education programme for medical professionals when dealing with children with down syndrome and additional needs who are neurodivergent".
She said they have agreement in principle with the HSE that future professional medical training will incorporate the KATE acronym.
K for Kind to emphasise that children and parents deal with so much more every day than typical parents a little bit of kindness will kelp the child and parent.
A for Alert to emphasise that the child may have serious medical problems and may be a lot sicker than they look.
T for Time to ensure time is taken to examine them very well as they may deteriorate quickly.
E for Experts to ask the experts – parents or guardians who are the experts on their child and recognising that their input in invaluable.
Ms Colum told the inquest that a post about her daughter’s death was published on a medical professional’s social media page before they had an opportunity to tell their immediate family.
The jury of four men and three women returned a unanimous verdict of death as a result of medical misadventure.
The jury recommended that the KATE acronym is promoted in future training of medical personnel in treating children with additional needs.
"Kate's life was a blessing and her memory a treasure. She is loved beyond words and missed beyond measure"
Coroner Fergal Kelly said with the acronym KATE – that Kate Colum’s name will live long into the future.
Mr Kelly said he wrote down three words that stood out during the depositions of Claire and Matthew Colum - love, family and remembrance.
Mr Kelly said it was very clear that Kate was loved by her family and extended family. He sympathised with the Colum family on their daughter’s passing.
Following the inquest, the family said the Kate pneumonic memory of their daughter had the full backing of the HSE.
"We can now continue to develop this further with the hope being that medical professionals remember Kate and that this saves another child and family from something similar.
"Kate changed our lives in so many amazing ways. She will continue to pave the way for so many others going forward.
Ms Colum said her daughter led a very happy little life and although it was cut short, her life will be remembered as being "absolutely perfect".
"Kate's life was a blessing and her memory a treasure. She is loved beyond words and missed beyond measure".
