A verdict of medical misadventure has been recorded at an inquest which heard of a fatal delay by a hospital in treating a young girl with a known brain condition who had suffered severe headaches for several hours and was "screaming in pain".
Dublin District Coroner's Court heard a simple procedure to drain fluid from the patient’s brain could have been performed within a few minutes that could have saved her life.
A representative of Children’s Health Ireland at Temple Street in Dublin issued an apology and profound regret to the family of Lily Daly at the conclusion of the inquest into her death for the "tragic consequences" while under the care of the hospital six years ago.
Lily, aged seven, from Ben Edair Road, Stoneybatter, Dublin died at CHI at Temple Street on 9 February 2019 - the day after she had suffered a cardiac arrest while having an MRI scan.
The inquest heard that the young girl had a condition since birth which made her prone to hydrocephalus - an abnormal build-up of fluid in the brain.
'Screaming in pain'
Lily’s mother gave evidence that her daughter was brought to Temple Street on the morning of 8 February 2019 after she had been complaining of headaches and a sore throat since 1am.
She described how her daughter began vomiting and "screaming in pain" in the hospital but that they were repeatedly reassured by medical staff that her vital signs were normal.
However, Ms Maguire said she knew Lily’s condition was getting worse.
Although they had notified medical staff about Lily’s history with hydrocephalus, she said it was never raised by doctors examining her and they were never given a reason why she needed an MRI scan.
The inquest heard that at one stage, the girl’s eye went in opposite directions.
"It is a memory that will never leave us," Ms Maguire said.
The inquest heard how they were turned back from bringing Lily for the MRI scan after they were brought through a wrong entrance before one was carried out about 20 minutes later.
Ms Maguire outlined how she realised her daughter was not breathing while she was in the MRI scanner and they "fumbled" to get her out of the equipment.
The girl was rushed to theatre for emergency surgery to drain fluid from her brain but she had suffered irreparable damage and was pronounced dead the following day.
Ms Maguire revealed that Lily’s kidneys and heart valves had been donated to save other lives.
'An amazing young girl'
She recalled her daughter as "an amazing young girl who was very bright and very sociable".
In reply to questions from coroner, Myra Cullinane, she said they were terrified when Lily had been discharged from ongoing care in 2014, but were told that any problem was only likely to appear gradually and they would have 24 hours to get treatment.
Consultant neurosurgeon, Darach Crimmins, who had treated Lily since she was a baby, gave evidence that her death might have been prevented if she had received immediate surgery rather than being sent for an MRI scan.
The inquest heard Prof Crimmins was performing surgery in Beaumont Hospital on the day she went to Temple Street but was being briefed about her condition by his registrar, Ellen O’Brien.
Prof Crimmins took full and sole responsibility for what happened and expressed profound regret that he had not instructed Dr O’Brien to arrange an immediate procedure to drain the fluid from the patient’s brain rather than arrange an MRI scan, particularly after she had called him a second time that day at 4pm to notify him that Lily was very sick.
The consultant acknowledged he had not seen the patient and had not appreciated the concerns of his registrar about the patient.
Prof Crimmins, who became emotional during his evidence, said he had subsequently ceased all adult practice to concentrate on treating children so that a paediatric neurosurgeon was now available at all times at Temple Street.
"I remain deeply sorry that I didn’t make a different decision," he stated.
'I made completely the wrong decision'
He later added: "I made completely the wrong decision. I should have had the common sense to say 'things are not stable.’"
The inquest heard that Lily had been classified as a Category 2 patient on being triaged at 11.19am which meant she should be seen within 15 minutes.
A consultant in emergency medicine, Ike Okafor, gave evidence of examining the girl 20 minutes later in which he ordered a number of tests including a CT scan.
Dr Okafor said he subsequently discussed the results of the CT scan which was carried out at 12.23pm with Dr O’Brien who reported a marginal increase in the ventricles in the patient’s brain compared to a previous scan in 2011.
However, Dr Okafor said it was not an emergency situation as there were "no extreme findings".
"Her vital signs were reassuringly close to normal given the severity of the headaches. It was a mismatch," he remarked.
The consultant acknowledged that it would have been preferable if medical notes had recorded that Lily was suffering from severe headaches instead of just "headaches".
In evidence, Dr O’Brien said any patient with hydrocephalus was a concern.
The registrar said she had examined Lily at 2.25pm when she had appeared stable and noted that the earlier CT scan had shown no signs of acute hydrocephalus.
Following a phone consultation with Prof Crimmins, Dr O’Brien said the plan was to order an MRI scan although she expected that the girl would need surgery later that day because of her condition.
The witness said there was no doubt in her mind that she was dealing with a sick child who would require an intervention.
Potential 'red flag' signs
However, Dr O’Brien said she could not recall being informed of potential "red flag" signs displayed by Lily including problems with her vision and urinating on herself but stated it was likely she would have noted them if she had been told.
Recording a verdict of medical misadventure, Dr Cullinane said there had been evidence that medical staff had not acted in a timely fashion to intervene "with the least clinical course".
The coroner noted that a more junior decision maker was on site in Temple Street but the consultant neurosurgeon was working in Beaumont Hospital.
She also observed that there was a lack of full information being shared between decision makers about Lily’s condition.
Dr Cullinane said they were all factors which led to the patient’s untimely death.
The coroner noted and welcomed a series of changes that had been introduced at the hospital including additional consultants and nursing staff in the emergency department as well as MRI scanners.
Other measures include training on medical record keeping, communications and raised pressure on the brain in patients.
Counsel for Lily’s family, Roger Murray SC, said they greatly appreciated the hospital’s apology and they took some consolation from the fact that lessons had been learnt which might prevent similar fatalities in the future.
