A verdict of medical misadventure has been recorded at an inquest into the death of a 7-year-old girl who could have survived if immediate surgery had been performed rather than a planned “fancy surgery”.
A sitting of Dublin District Coroner’s Court heard on Friday that Lily Daly was brought to Temple Street hospital’s emergency department by her parents at around 10.45am on February 8th, 2019, due to a severe headache.
The 7-year-old from Stoneybatter had a history of hydrocephalus, a build-up of fluid on the brain due to a congenital condition.
Her mother, Olivea Maguire, recalled her daughter “screaming in pain” as she held the back of her head and began to vomit while going in and out of sleep at the emergency department.
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“We were reassured at all times that her vital signs were within normal limits,” Ms Maguire said.
A CT brain scan carried out at about 1pm showed signs of hydrocephalus and an MRI to assist in the surgery planned to relieve the fluid build-up was carried out at 4.30pm.
While in the MRI machine, the inquest heard how Lily became unresponsive, having suffered from cardiac arrest.
She was quickly transferred to a theatre to drain the fluid from her brain, though she did not regain consciousness and died on February 9th.
Darach Crimmins, a consultant paediatric neurosurgeon, who was operating at Beaumont Hospital when Lily’s case was raised with him twice by his registrar, Dr Ellen O’Brien, advised her to pursue the MRI needed to proceed with a particular surgical approach.
Although it was clear that Lily required treatment for hydrocephalus following the CT scan, he felt endoscopic third ventriculostomy (ETV) was the ideal treatment for her, and would have been of more benefit in the long-term, he said.
Prof Crimmins told the inquest that Lily’s death might have been prevented by external ventricular drainage (EVD) rather than arranging an MRI for the ETV.
“The decision to perform the MRI and the fancy surgery was mine alone, and I firmly regret not instructing Ellen to take Lily to theatre immediately for an EVD,” he said.
Prof Crimmins, who was in Beaumont when consulted on the matter, said he did not appreciate the severity of Lily’s symptoms at the time, and felt she was stable enough to have the MRI before ETV surgery, saying it is “sometimes something you have to see yourself”.
“I should have made the call to get her out of danger first and worry about the long-term after,” he said, later adding that he made “completely the wrong decision”.
Returning a verdict of medical misadventure, coroner Dr Myra Cullinane said: “There were lost opportunities to act in a timely fashion to intervene in Lily’s clinical course.”
These were due to several factors which were “causative to Lily’s untimely death”, including Prof Crimmins being off-site on the day, as well as a lack of full clinical information being available to share between both he and his registrar.
The inquest heard Dr O’Brien could not recall being informed of symptoms such as urinary incontinence or visual disturbances suffered by Lily while in the emergency department which would have been “red flags”.
These factors were “causative to Lily’s untimely death,” Dr Cullinane said.
She noted changes since made at the hospital’s emergency department such as an increased number of nurses and consultants, as well as communications training for staff.
Two more MRI scanners have been installed while training has been provided to emergency paediatric emergency departments across the country concerning hydrocephalus and its management.
Solicitor Declan Buckley, on behalf of Children’s Health Ireland at Temple Street, offered its “most sincere apologies” to the parents, “regarding the tragic death of your daughter Lily while she was under our care.”
Lily’s parents settled High Court action earlier this month for €168,000.
