An inquest into the death of a three month old baby at University Hospital Galway has heard how he died as a result of complications following an eye operation in 2016.
Jonathan Borges Gonclaves suffered irreparable brain damage due to oxygen deprivation and died a week after the procedure was carried out.
Born prematurely - at 25 weeks gestation - in February 2016, Jonathan Borges Gonclaves was diagnosed with a condition known as retinopathy of prematurity.
The condition can lead to visual impairment, but it can be treated effectively with laser surgery.
That was the course of action that was followed in this case at University Hospital Galway, but during the procedure, a critical drop in oxygen levels went undetected, with fatal consequences.
An MRI scan conducted the following day showed Oxygen levels to the baby’s brain had reduced, causing irreparable damage. Baby Jonathan died six days later.
The inquest heard that one of two devices to monitor those oxygen saturation levels had been inadvertently turned off before the treatment began.
Concerns were also raised about the workload placed on nurse managers and the manner in which staff were allocated for such procedures.
Galway West Coroner Dr Kieran McLoughlin returned a narrative verdict in line with the evidence given.
The HSE has apologised to the infant’s parents, who made no comment as they left the Coroner’s Court this evening.
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In his evidence, Dr Donough O'Donovan, Consultant Neonatologist at the hospital, detailed how the procedure was carried out.
Baby Jonathan had been sedated in advance and had been fitted with a high flow nasal cannula, in the event he would require oxygen.
An eye surgeon, a theatre nurse and a neonatal nurse were present for the operation.
Dr O'Donovan said these protocols were based on a practice that had been used successfully for years.
He told the coroner that the baby remained unresponsive in the hours after the procedure and a number of avenues were explored.
An MRI scan conducted the following day showed he had sustained a "significant hypoxic brain injury", which was a consequence of oxygen deprivation during the eye treatment. This scan revealed that oxygen levels to the brain had reduced, causing irreparable damage.
This was the first time the extent of the problem became clear to hospital staff.
Dr O'Donovan said in retrospect, it would have been better if other staff members had also been in a position to monitor the baby's vital signs while he was sedated. He said people were now responding in "a more active way" to monitoring alarms.
But he took issue with many of the findings of an external review into the case. He said there was no evidence to suggest that a head cooling technique would have benefited the baby.
He said it was "grossly unfair to suggest there was a treatment available that would have changed the outcome".
Clinical nurse manager, Maureen Sweeney, was present for the procedure. In her evidence, she told how a morphine infusion had been first administered at 11.20am on the morning in question.
She prepared the room for the procedure and was administering eye drops to baby Jonathan in the time before surgery was scheduled to start.
She told the inquest how she forgot to turn on a 'Nellcor' monitor, to check pulse and oxygen saturation levels, after becoming distracted when the baby's pupils were not adequately dilated before the procedure. While another monitor was active, she said the Nellcor one was the monitor she would have relied on, to react to any difficulties.
She outlined how the baby's heart rate and SpO2 (oxygen saturation levels) dropped during the procedure.
Ms Sweeney said a continuous alarm from the connected monitor was sounding through the procedure. But she said she had no concerns about the baby's condition until the operation was completed and the lights in the darkened room were turned back on.
Evidence about a repetitive alarm sound was contested by theatre nurse, Philomen Laurence, and consultant surgeon, Dr Eamon O'Donoghue, who said they had no recollection of a persistent alarm.
Dr O'Donoghue said he asked Nurse Sweeney at least 30 times during the procedure "is baby alright?" and that, at all times, he was told the infant was okay.
He had stopped working when asked to do so by the neonatal nurse, so she could check on the baby. He strenuously denied that he had ignored any such request.
He said he left the room feeling things had gone relatively well. Dr O'Donoghue said he would have stopped what he was doing if there was a continual alarm going off.
He was not aware of the serious condition that the baby was in until the next morning.
Coroner for Galway West, Dr Kieran McLoughlin, said he had sought a copy of the external review into the death, which had been carried out for the Health Service Executive.
But he had been told that the HSE did not provide such material to coroners.
Dr McLoughlin said he was surprised by this but was pleased that legal representatives for Jonathan Borges Gonclave's parents had obtained a copy of the report.
Counsel for the HSE, Oonagh McCrann, said it was the position of the State Claims Agency that independent external reviews should not form part of the coroner's inquest "in certain cases".
She told Dr McLoughlin this afternoon that the report in question was contentious and serious issue had been taken with some of its findings.
The inquest has been told how the review recommended a number of changes at the hospital's neonatal unit. These include enhanced central monitoring of procedures to ensure greater overview of patients' vital signs.
The hospital has also discontinued the practice of conducting laser eye surgeries on infants.