Children's Health Ireland has issued a "sincere apology" for shortcomings in the care of a Dublin teenager with severe and poorly controlled asthma who died following a severe attack while waiting over four years to see a specialist consultant.
Killian Burnett, aged 15, from Finglas, who passed away at Connolly Hospital in Blanchardstown on 22 March 2022, had four cancelled appointments between his first referral to see a consultant in respiratory medicine in December 2017 and his death.
Coroner Clare Keane returned a verdict of death due to medical misadventure at an inquest into the boy’s death at Dublin District Coroner’s Court.
Dr Keane noted there had been "missed opportunities" to treat his "unstable, severe asthma".
Welcoming improvements already made by CHI, the coroner recommended that consideration should be given to making it mandatory for any children presenting with a history of respiratory arrest due to asthma to be discussed with a senior clinician, with a referral made or the patient’s care escalated if clinical conditions warranted it.
Dr Keane said it should also be clarified if patients, who already had a referral, had been categorised as routine, semi-urgent or urgent and to change their status if necessary.
The inquest heard that Killian and his parents attended CHI at Temple Street in Dublin to see a specialist a month before his death without realising that, due to some miscommunication, the appointment had been cancelled a short time previously.
CHI revealed that it was one of only seven days since 2018 when no respiratory consultant was available during daytime hours to see patients.
Evidence was also heard that the teenager - a student at New Cross College in Finglas - had been discharged after a few hours, on five occasions that he had been brought by ambulance to Temple Street over the space of two months shortly before his death, including two occasions where he had lost consciousness.
The teenager’s father, David Burnett, told the inquest that Killian - the fourth eldest of his six children - had always been "a bit chesty" since he was very young.
Mr Burnett recalled Killian had his first serious asthma attack in February 2013 and required an ambulance to bring him to hospital after another incident in October 2016.
After one severe attack when he collapsed outside his school in November 2017 and was taken to Temple Street, he was placed on a nebuliser in addition to his regular inhalers and tablets.
As his son’s condition deteriorated, Mr Burnett said Killian lost interest in sport and was regularly sent home from school because he was complaining of chest pains.
He recalled that his son also became afraid to go to sleep as he would suffer an average of two asthma attacks every night.
Mr Burnett said the regularity of the attacks had resulted in him sleeping in his son’s bedroom to look after him which had affected his own ability to work due to exhaustion and pressure.
After another serious asthma attack in December 2021, CPR had to be performed on Killian after he stopped breathing for a few minutes.
Mr Burnett recalled his son became reluctant to go in an ambulance as he believed he would just get sent home after a few hours.
The inquest heard that Killian was told to reduce his use of inhalers when he was brought to CHI in Crumlin on 9 February 2022, after his family were advised to get a second opinion following another bad asthma attack the previous month.
On the day of his son’s death, Mr Burnett recalled being alerted at 4am that Killian was struggling to breathe and everyone in their house was screaming as his face went pale and his lips went purple.
Mr Burnett recounted how his son said: "Dad, please help me."
"This is something I relive every single day," he added.
Mr Burnett described his son as "everyone’s best friend" and a "great little kid".
Dr Martin Murphy, who examined the teenager in Crumlin, said he had been reassured that Killian had no acute asthma at the time as well as that he had an appointment to see a specialist two weeks later.
Under cross-examination by counsel for the deceased’s family, Alannah McGurk BL, Dr Murphy agreed that the patient had a concerning medical history and expressed regret for the decision that he had made given what subsequently happened.
Consultant in emergency medicine at CHI Michael Barrett said he believed the patient had received "timely and appropriate treatment" in Crumlin given his stable condition at the time.
Prof Barrett, who admitted being "dreadfully upset" about Killian’s death, said he did not know if he would have referred the teenager directly to a specialist if he had examined him that night.
He agreed with Ms McGurk that waiting to see a specialist for four years was certainly relevant but he was unsure what weight could be attached to the fact.
Prof Barrett also observed that the incident where Killian had stopped breathing during an asthma attack was "a life-threatening episode" which ordinarily would result in admission to hospital.
CHI’s clinical director for medical specialities, Michael Riordan, offered an "unreserved apology" to the deceased’s family for "acknowledged shortcomings" in the care of his condition.
Outlining changes that have been made by CHI since Killian’s death, Dr Riordan told his family that there was nothing he could say to bring him back.
"I’m sorry to say the only thing I have to offer them is an intention to do my best to try and stop something like this from happening again," said Dr Riordan.
He told the inquest that a serious incident report on Killian’s death had been circulated to all respiratory consultants, while waiting lists for such patients had been merged across all CHI hospitals to ensure "equity of access" based on clinical priority and time spent on waiting list.
"No patients are currently waiting for more than two years on the respiratory waiting list," he noted.
Dr Riordan said various referral pathways for children with asthma had been reviewed with reminders how referrals could be updated if there was a change in their clinical status.
The inquest heard Killian had been categorised as a "routine" case following his first referral - a status that never changed before his death.
Dr Riordan observed that patients categorised as "semi-urgent" still faced "a significant wait" at the time to be seen by a specialist.
He pointed out that CHI had reviewed its management of waiting lists for respiratory patients, while the HSE had also commissioned a similar independent review.
The inquest heard that a substantial amount of work was being undertaken by CHI around the time of Killian’s death to try to reduce waiting times for respiratory patients.
While they had fallen by the end of 2023, Dr Riordan said they have built up again due to significant demand, with 290 children waiting to be seen by a specialist last month.
He said 25 patients had been waiting over a year with the longest wait just over 15 months.
Dr Riordan said funding had been approved for two new consultant posts with one having started last March and another due to begin work in mid-2026.
Although CHI endeavours to meet and exceed the HSE’s targets for 50% of patients to be seen within ten weeks for their first outpatient appointment, Dr Riordan said success rates varied due to a combination of factors.
He pointed out that there are currently over 24,400 children waiting beyond the target to be seen for their first specialist appointment with the average waiting time 7 and a half months.
Multiple attendances at hospital striking, inquest told
Dr Riordan said Killian’s multiple attendances at the emergency department in Temple Street was a striking feature of the case.
He outlined how CHI was working to see if its IT systems could trigger a warning for children who have multiple hospital attendances with asthma and other potentially serious recurrent illnesses.
The inquest heard 994 children with asthma attended emergency departments last year on more than one occasion, including 46 who attended four or more times. In addition, 49 such patients were admitted to an intensive care unit.
Dr Riordan also noted that there were 586 children on the waiting list to be seen by a respiratory consultant in Temple Street in September 2022 with around 250 new patients being added each year.
Counsel for CHI, Conor Halpin SC, told the hearing that recommendations made by the Burnett family would be passed on to a committee reviewing clinical guidelines, although he noted that several measures were already covered.
Mr Halpin issued an apology on behalf of CHI’s chief executive Lucy Nugent for its shortcomings and acknowledged that "the experience was devastating for you".
A post-mortem examination confirmed Killian had died as a result of respiratory failure due to a severe exacerbation of chronic asthma.
The coroner noted that aspiration of gastrointestinal mucoid content and focal pneumonia were contributory factors.
Following the hearing, Killian’s eldest brother, Jordan, paid tribute to his younger brother and said the inquest was an important step to understanding everything that led up to his death.
"For years, we tried our best to support him and to get him the help he needed. As his brother, I saw him struggle in ways no child should ever have to, and those memories will stay with me for the rest of my life," said Mr Burnett.
"I wish more than anything that we were not standing here today. I wish my little brother was still with us - laughing, growing up, living his life the way he deserved. Instead, we are facing a future without him, and our family is carrying a pain that will stay with us forever."
Mr Burnett added: "Killian was never just a case number or a file. He was a bright, funny, loving boy who deserved to grow up and experience all the things life had to offer. He deserved a chance."
Accompanied by the family’s solicitor Ciara McPhillips, he expressed hope that no other family "ever has to go through what we have gone through".
